Healthcare Provider Details

I. General information

NPI: 1114986197
Provider Name (Legal Business Name): EAST BERNSTADT MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11901 N HIGHWAY 421 11901 NORTH HWY 421
MANCHESTER KY
40962-4859
US

IV. Provider business mailing address

11901 N HIGHWAY 421 11901 NORTH HWY 421
MANCHESTER KY
40962-4859
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-2706
  • Fax: 606-598-0856
Mailing address:
  • Phone: 606-598-2706
  • Fax: 606-598-0856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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