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General NPI Number Information
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NPI Number | 1164677332
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Entity Type | Organization
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Legal Business Name | CAROLINA PINES MEDICAL, PC
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Dates
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Enumeration Date | 12/01/2008
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Last Update Date | 02/10/2009
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Provider Practice Location Address
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Address Line | 3215 HENDERSON DR
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City | JACKSONVILLE
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State | NC
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Zip | 28546-5251
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Country | US
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Telephone | 910-347-5444
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Fax |
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Provider Business Mailing Address
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Address Line | 3215 HENDERSON DR
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City | JACKSONVILLE
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State | NC
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Zip | 28546-5251
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Country | US
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Telephone | 910-347-5444
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL PATRICK SHUSKO
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Credential | M.D.
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Telephone | 910-347-5444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 200301290
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 200301290
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License Number State | NC
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