Provider Demographics
NPI:1740300672
Name:MARK AND CAROL SOLOMON PTR
Entity type:Organization
Organization Name:MARK AND CAROL SOLOMON PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-680-0272
Mailing Address - Street 1:128 NEWBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1923
Mailing Address - Country:US
Mailing Address - Phone:847-680-0272
Mailing Address - Fax:847-360-1615
Practice Address - Street 1:128 NEWBERRY AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1923
Practice Address - Country:US
Practice Address - Phone:847-680-0272
Practice Address - Fax:847-360-1615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL358150Medicare ID - Type Unspecified