Healthcare Provider Details

I. General information

NPI: 1861029605
Provider Name (Legal Business Name): ELLI NICOLE LOCKHART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLI JACOBSON

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 312-227-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number036.165767
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: