Basic Information
| Provider Information | |||||||||
| NPI: | 1629654819 | ||||||||
| 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 | ||||||||
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| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3995 OLD TOWN RD STE 201 | ||||||||
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| City: | HUNTINGTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206393041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037773262 | ||||||||
| FaxNumber: | 7037773365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2021 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | NORTON | ||||||||
| AuthorizedOfficialFirstName: | KARYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5717072048 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP, PC | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 1679591440 | 05 | VA | MEDICAID |