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General NPI Number Information
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NPI Number | 1184594962
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Entity Type | Organization
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Legal Business Name | BASIL FOSSUM MD PA
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Dates
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Enumeration Date | 11/07/2025
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 914B MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6706
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Country | US
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Telephone | 850-862-2555
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Fax | 850-862-8564
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Provider Business Mailing Address
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Address Line | 914B MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6706
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Country | US
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Telephone | 850-862-2555
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Fax | 850-862-8564
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNIFER LORD
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Credential |
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Telephone | 850-862-2555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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