Basic Information
| Provider Information | |||||||||
| NPI: | 1609900208 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOUDOUN MEDICAL GROUP, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANCINI AND KORKOWSKI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 44055 RIVERSIDE PKWY STE 216 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201765176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038581395 | ||||||||
| FaxNumber: | 7038587468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAMASY | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CG8680 | 01 | DC | RR MEDICARE PIN | OTHER | CG8678 | 01 | VA | RR MEDICARE PIN | OTHER |