Provider Demographics
NPI:1992318067
Name:LOUDOUN MEDICAL GROUP, PC
Entity type:Organization
Organization Name:LOUDOUN MEDICAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMASY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-737-6010
Mailing Address - Street 1:224D CORNWALL ST NW STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6000
Mailing Address - Fax:
Practice Address - Street 1:224-D CORNWALL ST, NW
Practice Address - Street 2:SUITE 204
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2700
Practice Address - Country:US
Practice Address - Phone:703-737-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUDOUN MEDICAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-28
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI1675951440Medicaid
VA1675951440Medicaid