Basic Information
| Provider Information | |||||||||
| NPI: | 1457678773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RED MOUNTAIN INTERNAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 804 | ||||||||
| Address2: | |||||||||
| City: | MANITOU SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808290804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202615141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 FAIRHURST ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807514523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705220122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 03/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | BRESNAHAN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7202615141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 43658 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 43658 | 01 | CO | CO LIC | OTHER |