Provider Demographics
NPI:1811573009
Name:LOUDOUN MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:LOUDOUN MEDICAL GROUP, PC
Other - Org Name:DME
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:703-737-6001
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:703-737-6001
Mailing Address - Fax:
Practice Address - Street 1:24430 STONE SPRINGS BLVD UNIT 100
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20166-2269
Practice Address - Country:US
Practice Address - Phone:703-737-3262
Practice Address - Fax:703-737-3365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUDOUN MEDICAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-19
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1679591440Medicaid