Provider Demographics
NPI:1376649061
Name:SOUTH RYAN MRI, LLC
Entity Type:Organization
Organization Name:SOUTH RYAN MRI, LLC
Other - Org Name:SOUTHWEST LOUISIANA IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRDLIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-439-7778
Mailing Address - Street 1:PO BOX 3184
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-3184
Mailing Address - Country:US
Mailing Address - Phone:337-439-7778
Mailing Address - Fax:337-433-4686
Practice Address - Street 1:1601 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5325
Practice Address - Country:US
Practice Address - Phone:337-439-7778
Practice Address - Fax:337-433-4686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445525Medicaid
LADA6047OtherRAILROAD MEDICARE
LA1445525Medicaid
LA1445525Medicaid