Healthcare Provider Details

I. General information

NPI: 1336109644
Provider Name (Legal Business Name): EAST BERNSTADT MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 HIGHWAY 3444
ANNVILLE KY
40402-8245
US

IV. Provider business mailing address

2659 NORTH LAUREL ROAD P O BOX 495
EAST BERNSTADT KY
40729-0000
US

V. Phone/Fax

Practice location:
  • Phone: 606-364-5162
  • Fax: 606-364-3920
Mailing address:
  • Phone: 606-843-6195
  • Fax: 606-843-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARLA JEAN JOHNSON
Title or Position: BILLING/CREDENTIALING CLERK
Credential:
Phone: 606-843-6195