Provider Demographics
NPI:1639120769
Name:ST GEORGE, TERESA ANGELA VENDITTO (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:ANGELA VENDITTO
Last Name:ST GEORGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TERESA
Other - Middle Name:ANGELA
Other - Last Name:VENDITTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3605 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2923
Mailing Address - Country:US
Mailing Address - Phone:218-262-3441
Mailing Address - Fax:218-362-6989
Practice Address - Street 1:3605 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2923
Practice Address - Country:US
Practice Address - Phone:218-262-3441
Practice Address - Fax:218-362-6989
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46867207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080015131OtherMEDICARE
MN452433100Medicaid
MNI15448Medicare UPIN