Healthcare Provider Details

I. General information

NPI: 1417158130
Provider Name (Legal Business Name): SHAREEN ISMAIL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8016 EAST GENESEE STREET THE ALEXANDRE CENTRE FOR CHILDREN'S HEALTH
FAYETTEVILLE NY
13066
US

IV. Provider business mailing address

3 QUAKER HILL RD
SYRACUSE NY
13224-2011
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number304858
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number304858
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: