Provider Demographics
NPI:1154911527
Name:BASIL D. FOSSUM, M.D. PA
Entity type:Organization
Organization Name:BASIL D. FOSSUM, M.D. PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOSSUM MD PA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-862-2555
Mailing Address - Street 1:914 MAR WALT DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6706
Mailing Address - Country:US
Mailing Address - Phone:850-226-6572
Mailing Address - Fax:
Practice Address - Street 1:914 MAR WALT DR STE B
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-226-6572
Practice Address - Fax:850-862-8564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-20
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME53505OtherMEDICAL LICENSE