Basic Information
| Provider Information | |||||||||
| NPI: | 1912449042 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOUDOUN MEDICAL GROUP . P.C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MATTHEW B GAVIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 224D CORNWALL ST NW | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376012 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24430 STONE SPRINGS BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DULLES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201662247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037773262 | ||||||||
| FaxNumber: | 7037773365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2016 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAMASY | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7037376012 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.