Basic Information
| Provider Information | |||||||||
| NPI: | 1386255602 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUDOUN MEDICAL GROUP . P.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224D CORNWALL ST NW STE 403 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376012 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7430 HERITAGE VILLAGE PLZ UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201553089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037533338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2020 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | STANTON | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7037376012 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP . P.C | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.