Provider Demographics
NPI:1225046154
Name:PIQUA FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:PIQUA FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LANDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:937-773-8221
Mailing Address - Street 1:9159 N COUNTY RD 25A
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356
Mailing Address - Country:US
Mailing Address - Phone:937-773-8221
Mailing Address - Fax:937-773-5117
Practice Address - Street 1:9159 N COUNTY RD 25A
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356
Practice Address - Country:US
Practice Address - Phone:937-773-8221
Practice Address - Fax:937-773-5117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046324207Q00000X
OH35087354207R00000X
OHNP07368363L00000X
OHRN305368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0766989Medicaid
85087354OtherLICENSE JORDAN
35046324OtherLICENSE LANDES
27752595700OtherWORKERS COMP LANDES
E60186OtherUPIN LANDES
OH0876146Medicaid
NP07368OtherLICENSE MCKEOWN
000000015687OtherANTHEM LANDES
319804D8200OtherWORKERS COMP JORDAN
000000015687OtherANTHEM LANDES
319804D8200OtherWORKERS COMP JORDAN
BL2173540OtherDEA LANDES
=========00OtherGROUP # WORKERS COMP
OH0766989Medicaid
OH0876146Medicaid
85087354OtherLICENSE JORDAN
BL2173540OtherDEA LANDES