Healthcare Provider Details

I. General information

NPI: 1205171741
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13890 BRADDOCK RD SUITE 206
CENTREVILLE VA
20121-2437
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 703-263-2333
  • Fax: 703-263-0361
Mailing address:
  • Phone: 703-737-6001
  • Fax: 571-291-9786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

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