Physician Compare National (NPI:1821043811)

HEALTHCARE PROVIDER: BASIL D. FOSSUM

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1821043811
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	7517150055
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20101018000299
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	FOSSUM
	Individual professional last name
Provider First Name	BASIL
	Individual professional first name
Provider Middle Name	D.
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	UNIVERSITY OF CALIFORNIA, SAN FRANCISCO SCHOOL OF MEDICINE
	Individual professional's medical school
Graduation Year	1972
	Individual professional's medical school graduation year
Primary Specialty	UROLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	21ST CENTURY ONCOLOGY, LLC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	9830082882
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	289
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	914 B MAR WALT DR
	Group Practice or individual's line 1 address
City	FORT WALTON BEACH
	Group Practice or individual's city
State	FL
	Group Practice or individual's state
Zip Code	325476706
	Group Practice or individual's zip code (9 digits when available)
Phone Number	8502266572
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	100223
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	FORT WALTON BEACH MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	100054
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	TWIN CITIES HOSPITAL
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	100292
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	SACRED HEART HOSPITAL ON THE EMERALD COAST
	Legal business name of hospital where individual professional provides service 3
Hospital Affiliation CCN 4	100266
	Medicare CCN of hospital where individual professional provides service 4
Hospital Affiliation LBN 4	GULF BREEZE HOSPITAL
	Legal business name of hospital where individual professional provides service 4
Professional Accepts Medicare Assignment	Y