1376649061 NPI number — SOUTH RYAN MRI, LLC

Table of content: (NPI 1376649061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376649061 NPI number — SOUTH RYAN MRI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH RYAN MRI, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1376649061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3184
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70602-3184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-439-7778
Provider Business Mailing Address Fax Number:
337-433-4686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70605-5325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-439-7778
Provider Business Practice Location Address Fax Number:
337-433-4686
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRDLIK
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
337-439-7778

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1445525 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA6047 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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