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	261QX0100X	Occupational Medicine Clinic/Center
2	261QP2300X	Primary Care Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
4	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46D2147193	OTHER	UT	CLIA

General Provider Information

NPI Number	:	1639713589
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	:	630 E 1400 N STE 150
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2549
Country	:	US
Telephone Number	:	435-915-4465
Fax Number	:	435-799-3664

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

Provider Enumeration Date	:	11/04/2019
Last Update Date	:	06/17/2026

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Directions to “STERLING PROVIDER GROUP ” Practice Location

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