Provider Demographics
NPI:1831158187
Name:EAST BERNSTADT MEDICAL CLINIC
Entity type:Organization
Organization Name:EAST BERNSTADT MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INS. BILLING CREDENTIALING CLERK
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:606-843-6195
Mailing Address - Street 1:US HWY 25 SOUTH
Mailing Address - Street 2:US HWY 25 SOUTH
Mailing Address - City:LILY
Mailing Address - State:KY
Mailing Address - Zip Code:40740
Mailing Address - Country:US
Mailing Address - Phone:606-523-1660
Mailing Address - Fax:606-523-1665
Practice Address - Street 1:US HWY 25 SOUTH
Practice Address - Street 2:US HWY 25 SOUTH
Practice Address - City:LILY
Practice Address - State:KY
Practice Address - Zip Code:40740
Practice Address - Country:US
Practice Address - Phone:606-523-1660
Practice Address - Fax:606-523-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65916660Medicaid
KY65916660Medicaid