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General NPI Number Information
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NPI Number | 1215432901
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Entity Type | Individual
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Provider Name | JASON QUALLEY MD, CCP,LP
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Gender | Male
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Dates
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Enumeration Date | 03/26/2018
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Last Update Date | 11/07/2024
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Provider Practice Location Address
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Address Line | 182 E REDSTONE AVE STE A
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City | CRESTVIEW
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State | FL
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Zip | 32539-5371
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Country | US
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Telephone | 855-527-7246
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Fax | 833-905-2461
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Provider Business Mailing Address
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Address Line | 201 DEFENSE HWY STE 205
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City | ANNAPOLIS
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State | MD
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Zip | 21401-7096
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Country | US
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Telephone | 855-527-7246
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Fax | 866-229-5063
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 613883
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | ME165604
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 242T00000X
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Taxonomy Name | Perfusionist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | ME165604
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License Number State | FL
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