1528712601 NPI number — LOUDOUN MEDICAL GROUP, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528712601 NPI number — LOUDOUN MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUDOUN MEDICAL GROUP, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KPC DIAGNOSTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528712601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224-D CORNWALL ST., NW SUITE 403
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20176-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-737-6010
Provider Business Mailing Address Fax Number:
703-443-8643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4445 WILLARD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHEVY CHASE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20815-3690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-372-0787
Provider Business Practice Location Address Fax Number:
703-712-7169
Provider Enumeration Date:
02/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
TAMASY
Authorized Official First Name:
MARY BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
703-737-6010

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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