1639120769 NPI number — DR. TERESA ANGELA VENDITTO ST GEORGE M.D.

Table of content: DR. TERESA ANGELA VENDITTO ST GEORGE M.D. (NPI 1639120769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639120769 NPI number — DR. TERESA ANGELA VENDITTO ST GEORGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST GEORGE
Provider First Name:
TERESA
Provider Middle Name:
ANGELA VENDITTO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VENDITTO
Provider Other First Name:
TERESA
Provider Other Middle Name:
ANGELA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639120769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3605 MAYFAIR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIBBING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55746-2923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-262-3441
Provider Business Mailing Address Fax Number:
218-362-6989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3605 MAYFAIR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIBBING
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55746-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-262-3441
Provider Business Practice Location Address Fax Number:
218-362-6989
Provider Enumeration Date:
05/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  46867 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 46867 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080015131 . This is a "MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 452433100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".