Provider Demographics
NPI:1821043811
Name:FOSSUM MD PA, BASIL D (MD, FACS)
Entity type:Individual
Prefix:
First Name:BASIL
Middle Name:D
Last Name:FOSSUM MD PA
Suffix:
Gender:M
Credentials:MD, FACS
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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:850-862-2555
Mailing Address - Fax:850-862-8564
Practice Address - Street 1:914B MAR WALT DR
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
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME53505174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07317OtherBCBS FL
FL1193041OtherWELLCARE
FL4266997OtherAETNA THRU EMERALD COAST HEALTH ALLIANCE
FL593-08600OtherBCBS AL
FLP00990540OtherRAILROAD MEDICARE
FL159401OtherUNIVERSAL HEALTHCARE
FL159401OtherUNIVERSAL HEALTHCARE
FLP00990540OtherRAILROAD MEDICARE
FL07317ZMedicare PIN