Healthcare Provider Details

I. General information

NPI: 1710001235
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 DEERFIELD AVENUE, SUITE 314
LEESBURG VA
20176-8472
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403
LEESBURG VA
20176-3346
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-7171
  • Fax: 703-723-7176
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

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