MEDICARE: EAST BERNSTADT MEDICAL CLINIC PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	363AM0700X	Medical Physician Assistant
3	207Q00000X	Family Medicine Physician
4	363L00000X	Nurse Practitioner
5	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114986197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BERNSTADT MEDICAL CLINIC PLLC

Provider Business Mailing Address
First Line	:	11901 N HIGHWAY 421
Second Line	:	11901 NORTH HWY 421
City	:	MANCHESTER
State	:	KY
Zip	:	40962-4859
Country	:	US
Telephone Number	:	606-598-2706
Fax Number	:	606-598-0856

Provider Business Practice Location Address
First Line	:	11901 N HIGHWAY 421
Second Line	:	11901 NORTH HWY 421
City	:	MANCHESTER
State	:	KY
Zip	:	40962-4859
Country	:	US
Telephone Number	:	606-598-2706
Fax Number	:	606-598-0856

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

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	10/29/2025

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Directions to “EAST BERNSTADT MEDICAL CLINIC PLLC ” Practice Location

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