Healthcare Provider Details

I. General information

NPI: 1023353976
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TOWN CENTER DR SUITE 214
RESTON VA
20190-3238
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 703-478-0325
  • Fax: 703-478-2702
Mailing address:
  • Phone: 703-737-6001
  • Fax: 571-291-9786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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