Healthcare Provider Details

I. General information

NPI: 1215246285
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7430 HERITAGE VILLAGE SUITE 101
GAINESVILLE VA
20155-3089
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW. SUITE 403
LEESBURG VA
20176-1334
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-3338
  • Fax: 703-753-7870
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

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