Healthcare Provider Details

I. General information

NPI: 1164677332
Provider Name (Legal Business Name): CAROLINA PINES MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 HENDERSON DR
JACKSONVILLE NC
28546-5251
US

IV. Provider business mailing address

3215 HENDERSON DR
JACKSONVILLE NC
28546-5251
US

V. Phone/Fax

Practice location:
  • Phone: 910-347-5444
  • Fax:
Mailing address:
  • Phone: 910-347-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200301290
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number200301290
License Number StateNC

VIII. Authorized Official

Name: DR. MICHAEL PATRICK SHUSKO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 910-347-5444