Provider Demographics
NPI:1477200244
Name:STERLING PROVIDER GROUP
Entity Type:Organization
Organization Name:STERLING PROVIDER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNNAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-542-9111
Mailing Address - Street 1:740 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5285
Mailing Address - Country:US
Mailing Address - Phone:208-542-9111
Mailing Address - Fax:208-542-9114
Practice Address - Street 1:5605 NORTHSIDE CROSSING ROAD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2431
Practice Address - Country:US
Practice Address - Phone:208-547-5062
Practice Address - Fax:208-547-5063
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STERLING PROVIDER GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13D2241709OtherCLIA