Provider Demographics
NPI:1215961560
Name:VERGELDT, JERI LEAH
Entity type:Individual
Prefix:
First Name:JERI
Middle Name:LEAH
Last Name:VERGELDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 KEENAN DR
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2181
Mailing Address - Country:US
Mailing Address - Phone:218-283-9431
Mailing Address - Fax:218-285-6275
Practice Address - Street 1:2501 KEENAN DR
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2181
Practice Address - Country:US
Practice Address - Phone:218-283-9431
Practice Address - Fax:218-285-6275
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN943365100Medicaid
WI32404700Medicaid
WI32404700Medicaid