Healthcare Provider Details

I. General information

NPI: 1306500665
Provider Name (Legal Business Name): PEACH STATE MEDICAL PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2021
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 19TH ST NW
WASHINGTON DC
20036-3603
US

IV. Provider business mailing address

333 S DESPLAINES ST STE 201
CHICAGO IL
60661-5514
US

V. Phone/Fax

Practice location:
  • Phone: 855-563-2639
  • Fax:
Mailing address:
  • Phone: 855-563-2639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: FAHIMEH SASAN
Title or Position: FOUNDING OBGYN
Credential: DO
Phone: 855-563-2639