Provider Demographics
NPI:1891390084
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:646-905-0987
Practice Address - Street 1:3005 PEACHTREE RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2214
Practice Address - Country:US
Practice Address - Phone:855-563-2639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KBI SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty