Healthcare Provider Details

I. General information

NPI: 1306892062
Provider Name (Legal Business Name): JAMES PEACOCK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PAGE ST
NEW BEDFORD MA
02740-3464
US

IV. Provider business mailing address

10 ORMS ST SUITE 110
PROVIDENCE RI
02904-2228
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-5006
  • Fax:
Mailing address:
  • Phone: 401-453-0666
  • Fax: 401-453-9619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA36627
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number255585
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: