Individual
PORTIA BONEBRAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2542 W NORTH AVE, CHICAGO, IL 60647-5216
(773) 365-7277
(773) 365-3091
Mailing address
2542 W NORTH AVE, CHICAGO, IL 60647-5216
(773) 365-7277
(773) 365-3091
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
036-112602
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036-112602
STATE LICENSE NUMBER
IL
01
—
036112602
BLUE SHIELD
—
05
—
036112602
—
IL
Enumeration date
12/11/2006
Last updated
10/28/2008
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