=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841967825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACH STATE MEDICAL PRACTICE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2021
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 138 N 2ND ST
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-563-2639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 S DESPLAINES ST STE 201
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60661-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-563-2639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDING OBGYB
-----------------------------------------------------
Name | DR. FAHIMEH SASAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 855-563-2639
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VE0102X
-----------------------------------------------------
Taxonomy Name | Reproductive Endocrinology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------