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General NPI Number Information
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NPI Number | 1891471280
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Entity Type | Organization
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Legal Business Name | PEACH STATE MEDICAL PRACTICE, PC
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Dates
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Enumeration Date | 06/22/2023
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Last Update Date | 05/20/2024
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Provider Practice Location Address
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Address Line | 3141 NE 1ST AVE
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City | MIAMI
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State | FL
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Zip | 33137
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Country | US
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Telephone | 305-735-2307
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Fax |
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Provider Business Mailing Address
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Address Line | 333 S DESPLAINES ST STE 201
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City | CHICAGO
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State | IL
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Zip | 60661-5514
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Country | US
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Telephone | 855-563-2639
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Fax |
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Authorized Official
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Title or Position | FOUNDING OBGYN
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Name | FAHIMEH SASAN
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Credential | DO
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Telephone | 855-563-2639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207VE0102X
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Taxonomy Name | Reproductive Endocrinology Physician
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License Number |
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License Number State |
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