Riverside Dermatology & Spa LLC

Primary specialty

Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X

Legal business name

RIVERSIDE DERMATOLOGY & SPA LLC

Practice address

163 Medical Dr
Hannibal, MO 63401-6884

Phone

(573) 822-4428

NPI assigned

Apr 18, 2018

Last updated

Apr 18, 2018By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Linda Cooke, MDNPI 1679552350

Title

Owner

Phone

(573) 822-3328

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MO

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Linda M Cooke, M.D.

  • Dermatology Physician
  • Hannibal, MO
  • NPI 1679552350
  Medicare reassignment Care Compare group Authorized official
• Emily Albright-Roberts, NP

  • Nurse Practitioner
  • Hannibal, MO
  • NPI 1396500559
  Medicare reassignment Care Compare group NPD
• Deana James, NP

  • Nurse Practitioner
  • Hannibal, MO
  • NPI 1487343810
  Medicare reassignment Care Compare group NPD
• Susan T Voss, N.P.

  • Family Medicine Physician
  • Louisiana, MO
  • NPI 1558379735
  Medicare reassignment Care Compare group NPD
• Tara Robertson, FNP-C

  • Family Nurse Practitioner
  • Mt Sterling, IL
  • NPI 1104204122

  MO

  Medicare reassignment Care Compare group NPD
• Katherine Glaser, M.D.

  • MOHS-Micrographic Surgery Physician
  • Hannibal, MO
  • NPI 1497100713

  Single Specialty

  Medicare reassignment NPD
• Kathleen E Haycraft, N.P.

  • Nurse Practitioner
  • Hannibal, MO
  • NPI 1508874736
  Medicare reassignment NPD
• Gabriella Ebers, PA

  • Physician Assistant
  • Hannibal, MO
  • NPI 1265194831
  Medicare reassignment

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1524009600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1524009600000",
    "number": "1699262329",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "163 MEDICAL DR",
            "city": "HANNIBAL",
            "state": "MO",
            "postal_code": "634016884",
            "telephone_number": "573-822-4428"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "163 MEDICAL DR",
            "city": "HANNIBAL",
            "state": "MO",
            "postal_code": "634016884",
            "telephone_number": "573-822-4428"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RIVERSIDE DERMATOLOGY & SPA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-04-18",
        "last_updated": "2018-04-18",
        "status": "A",
        "authorized_official_last_name": "COOKE",
        "authorized_official_first_name": "LINDA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "573-822-3328",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Andrea Colette Ridout, PTA
• Riney-Walden Inc
• Riney-Walden, Inc.
• Riney-Walden, Inc.
• Erin Riney
• Robert F. Munsch, M.D.
• Robert F. Munsch, M.D. P.C.
• Jennifer Elizabeth Roberts Merriman, D.O.
• Julia Marie Roberts
• James Robbie Robertson, D.C.

• Multi-Specialty Clinic/Center in Hannibal, MO
• Providers in Hannibal, MO by specialty
• Multi-Specialty Clinic/Center in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 18, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.