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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1598113730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUDOUN MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	PO BOX 17334
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21297-1334
Country	:	US
Telephone Number	:	703-443-6717
Fax Number	:	703-443-8643

Provider Business Practice Location Address
First Line	:	24430 STONE SPRINGS BLVD
Second Line	:	SUITE 250
City	:	DULLES
State	:	VA
Zip	:	20166-2247
Country	:	US
Telephone Number	:	703-858-3220
Fax Number	:	703-858-3221

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

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	08/18/2023

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