| Riverside Dermatology & Spa Llc | |
|
163 Medical Dr Hannibal MO 63401-6884 | |
| (573) 822-4428 | |
| Not Available |
| Full Name | Riverside Dermatology & Spa Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 163 Medical Dr, Hannibal, Missouri |
| Authorized Official Name and Position | Linda Cooke (OWNER) |
| Authorized Official Contact | 5738223328 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Riverside Dermatology & Spa Llc 163 Medical Dr Hannibal MO 63401-6884 Ph: (573) 822-4428 | Riverside Dermatology & Spa Llc 163 Medical Dr Hannibal MO 63401-6884 Ph: (573) 822-4428 |
| NPI Number | 1699262329 |
|---|---|
| Provider Enumeration Date | 04/18/2018 |
| Last Update Date | 04/18/2018 |
| Medicare PECOS PAC ID | 7214282227 |
|---|---|
| Medicare Enrollment ID | O20180615000066 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699262329 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| Provider Name | Linda M Cooke |
|---|---|
| Provider Type | Practitioner - Dermatology |
| Provider Identifiers | NPI Number: 1679552350 PECOS PAC ID: 1254311616 Enrollment ID: I20040726000084 |
| Provider Name | Kathleen E Haycraft |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1508874736 PECOS PAC ID: 4183779184 Enrollment ID: I20090826000858 |
| Provider Name | Susan T Voss |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1558379735 PECOS PAC ID: 0042365934 Enrollment ID: I20090828000062 |
| Provider Name | Tara K Robertson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1104204122 PECOS PAC ID: 2062707961 Enrollment ID: I20200513002515 |
| Provider Name | Katherine Sara Glaser |
|---|---|
| Provider Type | Practitioner - Dermatology |
| Provider Identifiers | NPI Number: 1497100713 PECOS PAC ID: 3971898818 Enrollment ID: I20220223001564 |
| Provider Name | Deana James |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1487343810 PECOS PAC ID: 2668816323 Enrollment ID: I20240221001522 |
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