Integrated Dermatology of Northeast Missouri LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

INTEGRATED DERMATOLOGY OF NORTHEAST MISSOURI LLC

Practice address

163 Medical Dr
Hannibal, MO 63401-6884

Phone

(573) 719-1818

NPI assigned

Jan 28, 2025

Organization subpart

No

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

Authorized official

Name

Jeffrey Queen

Title

Authorized Official

Phone

(561) 231-2635

Specialties & licenses 1

Addresses

Other names 1

• Integrated Dermatology of Northeast Missouri LLC Former legal business name

Medicare fee-for-service enrollment

Enrolled in MO

Enrollment records 1

Locations

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Emily Albright-Roberts, NP

  • Nurse Practitioner
  • Hannibal, MO
  • NPI 1396500559
  Medicare reassignment NPD
• Linda M Cooke, M.D.

  • Dermatology Physician
  • Hannibal, MO
  • NPI 1679552350
  Medicare reassignment NPD
• Deana James, NP

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

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

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

  MO

  Medicare reassignment NPD
• Gabriella Ebers, PA

  • Physician Assistant
  • Hannibal, MO
  • NPI 1265194831
  NPD
• Katherine Glaser, M.D.

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

  Single Specialty

  NPD
• Kathleen E Haycraft, N.P.

  • Nurse Practitioner
  • Hannibal, MO
  • NPI 1508874736
  NPD
• Robert W Benson, M.D.

  • Dermatology Physician
  • Ponchatoula, LA
  • NPI 1962406843
  NPD (past)

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

{
    "created_epoch": "1738022400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1738022400000",
    "number": "1992518658",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 EXCHANGE CT STE 110",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334314450",
            "telephone_number": "561-314-2000"
        },
        {
            "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": "573-719-1818"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRATED DERMATOLOGY OF NORTHEAST MISSOURI LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-01-28",
        "last_updated": "2025-01-28",
        "certification_date": "2025-01-28",
        "status": "A",
        "authorized_official_last_name": "QUEEN",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "561-231-2635"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Integrated Dermatology of Northeast Missouri LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Brooklynn Imhof, FNP
• Justin Imhof, D.O.
• Kevin B Imhof, D.O.
• Emma Inglis
• Amanda M Ingram, RN
• International Eyecare Center, Inc
• International Eyecare Center, Inc.
• Viacheslav Iremashvili, M.D.
• Jackson Group Home LLC
• Jackson Group Home LLC

• Dermatology Physician in Hannibal, MO
• Providers in Hannibal, MO by specialty
• Dermatology Physician in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.