Provider Demographics
NPI:1407464092
Name:LOUDOUN MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:LOUDOUN MEDICAL GROUP, PC
Other - Org Name:DIGESTIVE DISEASE PHYSICIANS
Other - Org Type:Doing Business As
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:703-737-6010
Mailing Address - Fax:571-291-9786
Practice Address - Street 1:4660 KENMORE AVE STE 500
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1300
Practice Address - Country:US
Practice Address - Phone:703-757-5763
Practice Address - Fax:703-370-8704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUDOUN MEDICAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-20
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1675951440Medicaid