Basic Information
| Provider Information | |||||||||
| NPI: | 1477004042 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUDOUN MEDICAL GROUP, P.C. | ||||||||
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| OtherOrganizationName: | DIGESTIVE DISEASE PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224D CORNWALL ST NW | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8988 LORTON STATION BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220794756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037515763 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | TAMASY | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7037376001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP, P.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.