Organization
PROVIDENCE PHYSICIAN GROUP INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JIM BLAIR (CEO)
(918) 684-2557
Entity
Organization
Contact information
Practice address
300 ROCKEFELLER DR, MUSKOGEE, OK 74401-5075
(918) 684-2557
(405) 948-6507
Mailing address
PO BOX 1664, MUSKOGEE, OK 74402-1664
(405) 947-8585
(405) 948-6507
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
—
—
367500000X
Certified Registered Nurse Anesthetist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3159009
AETNA
OK
01
—
DA6664
RAILROAD MEDICARE
OK
Enumeration date
06/15/2006
Last updated
09/11/2025
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