Healthcare Provider Details

I. General information

NPI: 1467374884
Provider Name (Legal Business Name): VIENNA MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MAPLE AVE W STE 420
VIENNA VA
22180-4301
US

IV. Provider business mailing address

301 MAPLE AVE W STE 420
VIENNA VA
22180-4301
US

V. Phone/Fax

Practice location:
  • Phone: 978-265-6436
  • Fax:
Mailing address:
  • Phone: 978-265-6436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SIVARAM YAMAJALA
Title or Position: SOLE MBR
Credential: YAMAJALA
Phone: 978-265-6436