Provider Demographics
NPI:1629192141
Name:LOUDOUN MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:LOUDOUN MEDICAL GROUP, PC
Other - Org Name:MATTHEW B GAVIN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAPSLEY
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:703-777-3262
Mailing Address - Fax:703-777-3365
Practice Address - Street 1:19 FORT EVANS RD NE STE C
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4487
Practice Address - Country:US
Practice Address - Phone:703-777-3262
Practice Address - Fax:703-777-3365
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
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACG8678OtherRR MEDICARE PIN
VAC06319Medicare PIN