MEDICARE: JAMES PEACOCK CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	082165-23	NH
2	367500000X	Certified Registered Nurse Anesthetist	RNA36627	RI
3	367500000X	Certified Registered Nurse Anesthetist	255585	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1286	OTHER	RI	BLUE CROSS PROVIDER NUMBER
2	001803	OTHER	RI	BLUE CHIP PROVIDER NUMBER
3	1306892062	OTHER	MA	FALLON

General Provider Information

NPI Number	:	1306892062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES PEACOCK CRNA

Provider Business Mailing Address
First Line	:	10 ORMS ST
Second Line	:	SUITE 110
City	:	PROVIDENCE
State	:	RI
Zip	:	02904-2228
Country	:	US
Telephone Number	:	401-453-0666
Fax Number	:	401-453-9619

Provider Business Practice Location Address
First Line	:	1 MEDICAL CENTER DR
Second Line	:
City	:	LEBANON
State	:	NH
Zip	:	03756-1000
Country	:	US
Telephone Number	:	603-650-5000
Fax Number	:	603-640-1228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	01/29/2026

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