Healthcare Provider Details

I. General information

NPI: 1497340939
Provider Name (Legal Business Name): RED MOUNTAIN INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2021
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 PHAY AVE
CANON CITY CO
81212-2311
US

IV. Provider business mailing address

PO BOX 804
MANITOU SPRINGS CO
80829-0804
US

V. Phone/Fax

Practice location:
  • Phone: 719-219-2400
  • Fax: 719-219-2409
Mailing address:
  • Phone: 720-261-5141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY MICHAEL BRESNAHAN
Title or Position: AUTHORIZED OFFICAL
Credential: MD
Phone: 720-261-5141