MEDICARE: PORTIA BONEBRAKE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	036-112602	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036-112602	OTHER	IL	STATE LICENSE NUMBER
2	036112602	OTHER		BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073673760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PORTIA BONEBRAKE M.D.

Provider Business Mailing Address
First Line	:	2542 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5216
Country	:	US
Telephone Number	:	773-365-7277
Fax Number	:	773-365-3091

Provider Business Practice Location Address
First Line	:	2542 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5216
Country	:	US
Telephone Number	:	773-365-7277
Fax Number	:	773-365-3091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	10/28/2008

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