Provider Demographics
NPI:1386227809
Name:PEACH STATE MEDICAL PRACTICE, PC
Entity type:Organization
Organization Name:PEACH STATE MEDICAL PRACTICE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDING OBGYN
Authorized Official - Prefix:
Authorized Official - First Name:FAHIMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:SASAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:855-563-2639
Mailing Address - Street 1:333 S DESPLAINES ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5514
Mailing Address - Country:US
Mailing Address - Phone:855-563-2639
Mailing Address - Fax:
Practice Address - Street 1:811 STEWART ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1305
Practice Address - Country:US
Practice Address - Phone:855-563-2639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty