MEDICARE: STERLING PROVIDER GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QP2300X	Primary Care Clinic/Center
2	261QX0100X	Occupational Medicine Clinic/Center
3	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13D2175156	OTHER	ID	CLIA

General Provider Information

NPI Number	:	1376312520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STERLING PROVIDER GROUP

Provider Business Mailing Address
First Line	:	740 S WOODRUFF AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-5285
Country	:	US
Telephone Number	:	208-542-9111
Fax Number	:	208-542-9114

Provider Business Practice Location Address
First Line	:	6965 N GLENWOOD ST
Second Line	:
City	:	GARDEN CITY
State	:	ID
Zip	:	83714-1967
Country	:	US
Telephone Number	:	208-853-3000
Fax Number	:	208-542-9114

Authorized Official
Title or Position	:	PROVIDER/OWNER
Name	:	CORBIN BUNNAGE
Credential	:	PA-C
Telephone Number	:	208-542-9111

Provider Enumeration Date	:	12/29/2023
Last Update Date	:	04/25/2024

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Directions to “STERLING PROVIDER GROUP ” Practice Location

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