Provider Demographics
NPI:1962116806
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:DR
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:
Mailing Address - Fax:
Practice Address - Street 1:6000 EXECUTIVE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-3858
Practice Address - Country:US
Practice Address - Phone:301-363-0226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACH STATE MEDICAL PRACTICE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-05
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