Provider Demographics
NPI:1003356452
Name:PERSONAL CARE HOME C&G, INC
Entity Type:Organization
Organization Name:PERSONAL CARE HOME C&G, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:QUARTEY
Authorized Official - Suffix:
Authorized Official - Credentials:PDM
Authorized Official - Phone:215-471-1407
Mailing Address - Street 1:6176 NEWTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-5928
Mailing Address - Country:US
Mailing Address - Phone:267-978-3040
Mailing Address - Fax:
Practice Address - Street 1:4104 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2614
Practice Address - Country:US
Practice Address - Phone:215-223-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-05
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251E00000XAgenciesHome Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038419160001Medicaid