Basic Information
| Provider Information | |||||||||
| NPI: | 1811573009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUDOUN MEDICAL GROUP . P.C | ||||||||
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| OtherOrganizationName: | DME | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24430 STONE SPRINGS BLVD UNIT 100 | ||||||||
| Address2: | |||||||||
| City: | DULLES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201662269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037373262 | ||||||||
| FaxNumber: | 7037373365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2021 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | TAMASY | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7037376001 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP . P.C | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
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 |