Basic Information
| Provider Information | |||||||||
| NPI: | 1639713589 | ||||||||
| 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: | 630 E 1400 N STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843412549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4359154465 | ||||||||
| FaxNumber: | 4357993664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2019 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUNNAGE | ||||||||
| AuthorizedOfficialFirstName: | CORBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2085429111 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 |
ID Information
| ID | Type | State | Issuer | Description | 46D2147193 | 01 | UT | CLIA | OTHER |