Basic Information
| Provider Information | |||||||||
| NPI: | 1568084515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STERLING PROVIDER GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 S WOODRUFF AVE | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834015285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085429111 | ||||||||
| FaxNumber: | 2085429114 | ||||||||
| Practice Location | |||||||||
| Address1: | 2761 COMMERCIAL WAY | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829014753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073823064 | ||||||||
| FaxNumber: | 3073823303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2020 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUNNAGE | ||||||||
| AuthorizedOfficialFirstName: | CORBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2085429111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA | ||||||||
| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.