=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952369761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBORSIDE PEDIATRICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2006
-----------------------------------------------------
Last Update Date | 01/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 WILLIAMSON RD STE 100
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-5966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-664-2552
-----------------------------------------------------
Fax | 704-664-5382
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 WILLIAMSON RD STE 100
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-5966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-664-2552
-----------------------------------------------------
Fax | 704-664-5382
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRICIAN
-----------------------------------------------------
Name | DR. SHELLEY H RINKER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-664-2552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 35735
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------