=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225046154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIQUA FAMILY PRACTICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9159 N COUNTY RD 25A
-----------------------------------------------------
City | PIQUA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-773-8221
-----------------------------------------------------
Fax | 937-773-5117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9159 N COUNTY RD 25A
-----------------------------------------------------
City | PIQUA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-773-8221
-----------------------------------------------------
Fax | 937-773-5117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | ROBERT CHARLES LANDES
-----------------------------------------------------
Credential | MD PA
-----------------------------------------------------
Telephone | 937-773-8221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35046324
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35087354
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | NP07368
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN305368
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------