Healthcare Provider Details

I. General information

NPI: 1447907423
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 CENTREVILLE ROAD, SUITE 500
CENTERVILLE VA
20121
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-263-3393
  • Fax: 703-828-0943
Mailing address:
  • Phone: 571-209-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY BETH TAMASY
Title or Position: CEO
Credential:
Phone: 703-737-6010