MEDICARE: PEACH STATE MEDICAL PRACTICE, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician
2	207VE0102X	Reproductive Endocrinology Physician

General Provider Information

NPI Number	:	1013647569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACH STATE MEDICAL PRACTICE, PC

Provider Business Mailing Address
First Line	:	333 S DESPLAINES ST STE 201
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-5514
Country	:	US
Telephone Number	:	855-563-2639
Fax Number	:

Provider Business Practice Location Address
First Line	:	2203 S PROMENADE BLVD STE 5185
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-8722
Country	:	US
Telephone Number	:	855-563-2639
Fax Number	:	646-905-0987

Authorized Official
Title or Position	:	FOUNDING OBGYN
Name	:	DR. FAHIMEH SASAN
Credential	:	DO
Telephone Number	:	855-563-2639

Provider Enumeration Date	:	06/15/2022
Last Update Date	:	05/20/2024

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