Provider Demographics
NPI:1114182698
Name:SOLOMON, LISA P (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:P
Last Name:SOLOMON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 HARLEM RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-654-5342
Practice Address - Street 1:2202 HARLEM RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-654-5342
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125054302207L00000X
IL036.126428207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036126428Medicaid
IL125054302OtherMEDICAL TEMPORARY LICENSE
IL036126428Medicaid