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	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538792486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUDOUN MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	224D CORNWALL ST NW
Second Line	:	SUITE 403
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	:	7921 JONES BRANCH DRIVE, SUITE 311
Second Line	:
City	:	MCLEAN
State	:	VA
Zip	:	22102-3334
Country	:	US
Telephone Number	:	703-772-4428
Fax Number	:	571-384-6309

Authorized Official
Title or Position	:	CEO
Name	:	MARY BETH TAMASY
Credential	:
Telephone Number	:	703-737-6001

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	04/23/2024

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