Basic Information
| Provider Information | |||||||||
| NPI: | 1861436636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE PHYSICIAN GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1664 | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744021664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059478585 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 ROCKEFELLER DR | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744015075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186842557 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9186842557 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | DA6664 | 01 | OK | RAILROAD MEDICARE | OTHER | 3159009 | 01 | OK | AETNA | OTHER |