Basic Information
| Provider Information | |||||||||
| NPI: | 1225046154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIQUA FAMILY PRACTICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9159 N COUNTY RD 25A | ||||||||
| Address2: | |||||||||
| City: | PIQUA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377738221 | ||||||||
| FaxNumber: | 9377735117 | ||||||||
| Practice Location | |||||||||
| Address1: | 9159 N COUNTY RD 25A | ||||||||
| Address2: | |||||||||
| City: | PIQUA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377738221 | ||||||||
| FaxNumber: | 9377735117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LANDES | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9377738221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35046324 | OH | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 35087354 | OH | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | NP07368 | OH | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | RN305368 | OH | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0766989 | 05 | OH | MEDICAID | 85087354 | 01 | LICENSE JORDAN | OTHER | BJ9595072 | 01 | DEA JORDAN | OTHER | 35046324 | 01 | LICENSE LANDES | OTHER | 27752595700 | 01 | WORKERS COMP LANDES | OTHER | E60186 | 01 | UPIN LANDES | OTHER | MM1114228 | 01 | DEA MCKEOWN | OTHER | 0876146 | 05 | OH | MEDICAID | NP07368 | 01 | LICENSE MCKEOWN | OTHER | 000000015687 | 01 | ANTHEM LANDES | OTHER | 319804D8200 | 01 | WORKERS COMP JORDAN | OTHER | BL2173540 | 01 | DEA LANDES | OTHER |