Healthcare Provider Details

I. General information

NPI: 1447175138
Provider Name (Legal Business Name): MEDIVERSE PROFESSIONAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 MIDWEST RD STE 111
OAK BROOK IL
60523-8206
US

IV. Provider business mailing address

2210 MIDWEST RD STE 111
OAK BROOK IL
60523-8206
US

V. Phone/Fax

Practice location:
  • Phone: 888-632-1240
  • Fax: 312-807-3550
Mailing address:
  • Phone: 888-632-1240
  • Fax: 312-807-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: USMAN K QADEER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 607-738-0240