Basic Information
| Provider Information | |||||||||
| NPI: | 1285382820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUDOUN MEDICAL GROUP, P.C. | ||||||||
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| OtherOrganizationName: | PHYSICIANS PREMIERE WEIGHT AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224-D CORNWALL STREET, NW | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376010 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 21035 SYCOLIN ROAD, SUITE 180 | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201474311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037835673 | ||||||||
| FaxNumber: | 7032973919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2022 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | TAMASY | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7037376010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP, P.C. | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.