Healthcare Provider Details

I. General information

NPI: 1699695791
Provider Name (Legal Business Name): MEDIVERSE PROFESSIONAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2026
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 MIDWEST RD STE 111A
OAK BROOK IL
60523-1280
US

IV. Provider business mailing address

2210 MIDWEST RD STE 111A
OAK BROOK IL
60523-1280
US

V. Phone/Fax

Practice location:
  • Phone: 630-440-7786
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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