MEDICARE: LOUDOUN MEDICAL GROUP, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician

General Provider Information

NPI Number	:	1356738934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUDOUN MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	224D CORNWALL ST NW STE 403
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-2704
Country	:	US
Telephone Number	:	703-737-6001
Fax Number	:	703-443-8643

Provider Business Practice Location Address
First Line	:	4660 KENMORE AVE STE 600
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-1314
Country	:	US
Telephone Number	:	703-313-5060
Fax Number	:	703-313-9446

Authorized Official
Title or Position	:	CEO
Name	:	MARY BETH TAMASY
Credential	:
Telephone Number	:	703-737-6010

Provider Enumeration Date	:	04/21/2015
Last Update Date	:	08/18/2023

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