Basic Information
| Provider Information | |||||||||
| NPI: | 1588318174 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUDOUN MEDICAL GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 D CORNWALL STREET NW | ||||||||
| Address2: | STE 403 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376010 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 19450 DEERFIELD AVE | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201766821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712528119 | ||||||||
| FaxNumber: | 8007351643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2022 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | TAMASY | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7037376010 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP, PC | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.