Basic Information
Provider Information | |||||||||
NPI: | 1962871392 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOUDOUN MEDICAL GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VIRGINIA HEARTBURN AND HERNIA INSTITUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224-D CORNWALL ST., NW, SUITE 403 | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201762704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037376010 | ||||||||
FaxNumber: | 7034438643 | ||||||||
Practice Location | |||||||||
Address1: | 8988 LORTON STATION BLVD, SUITE 202 | ||||||||
Address2: |   | ||||||||
City: | LORTON | ||||||||
State: | VA | ||||||||
PostalCode: | 220794758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7033922280 | ||||||||
FaxNumber: | 7033722024 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2015 | ||||||||
LastUpdateDate: | 09/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAMASY | ||||||||
AuthorizedOfficialFirstName: | MARYBETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7037376010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LOUDOUN MEDICAL GROUP, PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.