Basic Information
Provider Information | |||||||||
NPI: | 1336638675 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOUDOUN MEDICAL GROUP, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LOUDOUN PULMONARY AND SLEEP MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224D CORNWALL ST NW STE 403 | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201762704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037376001 | ||||||||
FaxNumber: | 7034438643 | ||||||||
Practice Location | |||||||||
Address1: | 19490 SANDRIDGE WAY, SUITE 210 | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201763467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037237504 | ||||||||
FaxNumber: | 7037237550 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2018 | ||||||||
LastUpdateDate: | 09/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAMASY | ||||||||
AuthorizedOfficialFirstName: | MARY BETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7037376010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP, P.C. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.