Provider Demographics
NPI:1457475873
Name:LOUDOUN MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:LOUDOUN MEDICAL GROUP, PC
Other - Org Name:LOUDOUN PEDIATRIC ASSOCIATES
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:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19500 SANDRIDGE WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-3688
Practice Address - Country:US
Practice Address - Phone:703-723-7337
Practice Address - Fax:703-723-8278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUDOUN MEDICAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06628Medicare PIN
VAC06319Medicare PIN