Healthcare Provider Details

I. General information

NPI: 1770317166
Provider Name (Legal Business Name): ISMAIL MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8016 E GENESEE ST
FAYETTEVILLE NY
13066-9692
US

IV. Provider business mailing address

8016 E GENESEE ST
FAYETTEVILLE NY
13066-9692
US

V. Phone/Fax

Practice location:
  • Phone: 315-569-1612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code2278P3900X
TaxonomyNeonatal/Pediatric Certified Respiratory Therapist
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAREEN ISMAIL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 315-569-1612