Healthcare Provider Details

I. General information

NPI: 1861436636
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ROCKEFELLER DR
MUSKOGEE OK
74401-5075
US

IV. Provider business mailing address

PO BOX 1664
MUSKOGEE OK
74402-1664
US

V. Phone/Fax

Practice location:
  • Phone: 918-684-2557
  • Fax: 405-948-6507
Mailing address:
  • Phone: 405-947-8585
  • Fax: 405-948-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JIM BLAIR
Title or Position: CEO
Credential:
Phone: 918-684-2557