Provider Demographics
NPI:1962063305
Name:MTA MEDICAL GROUP LLC
Entity type:Organization
Organization Name:MTA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AINUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SADYGULOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-269-4539
Mailing Address - Street 1:2620 S PARKER RD STE 273
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1627
Mailing Address - Country:US
Mailing Address - Phone:720-269-4539
Mailing Address - Fax:720-269-4539
Practice Address - Street 1:2620 S PARKER RD STE 273
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1627
Practice Address - Country:US
Practice Address - Phone:720-269-4539
Practice Address - Fax:720-269-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36157938OtherSTATE TAX LICENCE