Healthcare Provider Details

I. General information

NPI: 1376649061
Provider Name (Legal Business Name): SOUTH RYAN MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 COUNTRY CLUB RD
LAKE CHARLES LA
70605-5325
US

IV. Provider business mailing address

PO BOX 3184
LAKE CHARLES LA
70602-3184
US

V. Phone/Fax

Practice location:
  • Phone: 337-439-7778
  • Fax: 337-433-4686
Mailing address:
  • Phone: 337-439-7778
  • Fax: 337-433-4686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES J. BRDLIK
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 337-439-7778