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General NPI Number Information
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NPI Number | 1073673760
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Entity Type | Individual
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Provider Name | PORTIA BONEBRAKE M.D.
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Gender | Female
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 10/28/2008
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Provider Practice Location Address
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Address Line | 2542 W NORTH AVE
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City | CHICAGO
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State | IL
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Zip | 60647-5216
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Country | US
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Telephone | 773-365-7277
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Fax | 773-365-3091
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Provider Business Mailing Address
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Address Line | 2542 W NORTH AVE
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City | CHICAGO
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State | IL
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Zip | 60647-5216
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Country | US
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Telephone | 773-365-7277
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Fax | 773-365-3091
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036-112602
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License Number State | IL
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