Healthcare Provider Details

I. General information

NPI: 1215706452
Provider Name (Legal Business Name): STERLING PROVIDER GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2023
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 CALDWELL BLVD
NAMPA ID
83651-1728
US

IV. Provider business mailing address

740 S WOODRUFF AVE
IDAHO FALLS ID
83401-5285
US

V. Phone/Fax

Practice location:
  • Phone: 208-207-8500
  • Fax: 208-542-9114
Mailing address:
  • Phone: 208-542-9111
  • Fax: 208-542-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CORBIN BUNNAGE
Title or Position: PROVIDER/OWNER
Credential: PA-C
Phone: 208-542-9111