Basic Information
| Provider Information | |||||||||
| NPI: | 1669443909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STARLEY | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | Q | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 775 POLE LINE RD W | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101239001 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 12112 | ND | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | M-12760 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1669443909 | 05 | ID | MEDICAID |