Healthcare Provider Details

I. General information

NPI: 1073673760
Provider Name (Legal Business Name): PORTIA BONEBRAKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2542 W NORTH AVE
CHICAGO IL
60647-5216
US

IV. Provider business mailing address

2542 W NORTH AVE
CHICAGO IL
60647-5216
US

V. Phone/Fax

Practice location:
  • Phone: 773-365-7277
  • Fax: 773-365-3091
Mailing address:
  • Phone: 773-365-7277
  • Fax: 773-365-3091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-112602
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: