Basic Information
| Provider Information | |||||||||
| NPI: | 1639120769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST GEORGE | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | ANGELA VENDITTO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VENDITTO | ||||||||
| OtherFirstName: | TERESA | ||||||||
| OtherMiddleName: | ANGELA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2183626989 | ||||||||
| Practice Location | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2183626989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 46867 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 46867 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080015131 | 01 | MN | MEDICARE | OTHER | 452433100 | 05 | MN | MEDICAID |