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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1447747027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUDOUN MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	224D CORNWALL STREET, NW, STE 403
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-2704
Country	:	US
Telephone Number	:	703-737-6010
Fax Number	:	703-443-8643

Provider Business Practice Location Address
First Line	:	22365 BRODERICK DRIVE, SUITE 115
Second Line	:
City	:	STERLING
State	:	VA
Zip	:	20166-9362
Country	:	US
Telephone Number	:	703-996-4000
Fax Number	:	571-707-8123

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

Provider Enumeration Date	:	04/18/2018
Last Update Date	:	05/22/2023

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