Healthcare Provider Details

I. General information

NPI: 1457646606
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR SUITE 340
RESTON VA
20190-5896
US

IV. Provider business mailing address

PO BOX 17334
BALTIMORE MD
21297-1334
US

V. Phone/Fax

Practice location:
  • Phone: 703-858-3208
  • Fax: 703-547-9984
Mailing address:
  • Phone: 703-443-6717
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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