Provider Demographics
NPI:1629174339
Name:SECOND AVENUE MRI LLC
Entity Type:Organization
Organization Name:SECOND AVENUE MRI LLC
Other - Org Name:ADVANCED MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-494-2674
Mailing Address - Street 1:2770 3RD AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8994
Mailing Address - Country:US
Mailing Address - Phone:337-494-2674
Mailing Address - Fax:337-494-2694
Practice Address - Street 1:2770 3RD AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8994
Practice Address - Country:US
Practice Address - Phone:337-494-2674
Practice Address - Fax:337-494-2694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1448001Medicaid
LA5CS90Medicare PIN