Healthcare Provider Details

I. General information

NPI: 1295201895
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19500 SANDRIDGE WAY, SUITE 450
LEESBURG VA
20176-3467
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 703-656-9805
  • Fax: 703-729-6576
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

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