Provider Demographics
NPI:1164677332
Name:CAROLINA PINES MEDICAL, PC
Entity type:Organization
Organization Name:CAROLINA PINES MEDICAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:SHUSKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-347-5444
Mailing Address - Street 1:3215 HENDERSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5251
Mailing Address - Country:US
Mailing Address - Phone:910-347-5444
Mailing Address - Fax:
Practice Address - Street 1:3215 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5251
Practice Address - Country:US
Practice Address - Phone:910-347-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301290261QM2500X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2335854Medicare PIN