MEDICARE: LOUDOUN MEDICAL GROUP, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1043334410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUDOUN MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	224-D CORNWALL STREET, NW, SUITE 403
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-2704
Country	:	US
Telephone Number	:	703-737-6010
Fax Number	:	571-291-9786

Provider Business Practice Location Address
First Line	:	46165 WESTLAKE DR., STE 120
Second Line	:
City	:	POTOMAC FALLS
State	:	VA
Zip	:	20165-5872
Country	:	US
Telephone Number	:	703-444-3302
Fax Number	:	703-444-3240

Authorized Official
Title or Position	:	CEO
Name	:	MARY BETH TAMASY
Credential	:
Telephone Number	:	703-737-6010

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	09/27/2022

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