Healthcare Provider Details

I. General information

NPI: 1073829065
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19500 SANDRIDGE WAY, SUITE 110
LEESBURG VA
20176-3689
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 703-723-7337
  • Fax: 703-723-8278
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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