Provider Demographics
NPI:1912941865
Name:PEACOCK, ROBERT J (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-6001
Mailing Address - Country:US
Mailing Address - Phone:616-527-4200
Mailing Address - Fax:616-527-5731
Practice Address - Street 1:479 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-1834
Practice Address - Country:US
Practice Address - Phone:616-527-4200
Practice Address - Fax:616-527-5731
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704137243367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered