Provider Demographics
NPI:1013647569
Name:PEACH STATE MEDICAL PRACTICE, PC
Entity Type:Organization
Organization Name:PEACH STATE MEDICAL PRACTICE, PC
Other - Org Name:
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 1:120 5TH AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-5638
Mailing Address - Country:US
Mailing Address - Phone:855-563-2639
Mailing Address - Fax:
Practice Address - Street 1:2203 S PROMENADE BLVD STE 5185
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8722
Practice Address - Country:US
Practice Address - Phone:855-563-2639
Practice Address - Fax:646-905-0987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty