Active NPI
Portia Bonebrake, M.D.
- Psychiatry Physician
- Chicago, IL
National Provider Identifier
1073673760
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 036-112602
- Practice address
- 2542 W North Ave
Chicago, IL 60647-5216 - Phone
- (773) 365-7277
- Fax
- (773) 365-3091
- NPI assigned
- Dec 11, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 036-112602 | IL | Primary |
Addresses
Primary practice location
2542 W North Ave
Chicago, IL 60647-5216
Mailing address
2542 W North Ave
Chicago, IL 60647-5216
Phone (773) 365-7277
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036-112602 | Other | IL | STATE LICENSE NUMBER |
| 036112602 | Other | BLUE SHIELD | |
| 036112602 | Medicaid | IL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036-112602 | IL | MD | Psychiatry Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Overlake Medical Center & Clinics | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Psychiatric Hospital Unit
- Bellevue, WA
- NPI 1811904063
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1165795200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1225152000000",
"number": "1073673760",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2542 W NORTH AVE",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606475216",
"telephone_number": "773-365-7277",
"fax_number": "773-365-3091"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2542 W NORTH AVE",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606475216",
"telephone_number": "773-365-7277",
"fax_number": "773-365-3091"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BONEBRAKE",
"first_name": "PORTIA",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-12-11",
"last_updated": "2008-10-28",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "IL",
"license": "036-112602",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE NUMBER",
"identifier": "036-112602",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE SHIELD",
"identifier": "036112602",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036112602",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.