=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538792486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUDOUN MEDICAL GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2020
-----------------------------------------------------
Last Update Date | 04/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7921 JONES BRANCH DRIVE, SUITE 311
-----------------------------------------------------
City | MCLEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-772-4428
-----------------------------------------------------
Fax | 571-384-6309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224D CORNWALL ST NW SUITE 403
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-737-6010
-----------------------------------------------------
Fax | 703-443-8643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARY BETH TAMASY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-737-6001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------