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BASIL D. FOSSUM, M.D. PA
NPI 1154911527
Urology in Fort Walton Beach, FL

Active since January 20, 2021CLIA 10D2284940 · Microscopy
914 MAR WALT DR STE B, FORT WALTON BEACH, FL 32547(850) 226-6572(850) 862-8564 Get Directions Write a Review

NPPES record last updated: May 22, 2025. Verified against the NPPES registry weekly; last sync: August 09, 2026.

Record update history: May 22, 2025, Apr 1, 2021, Jan 20, 2021 (3 updates tracked since 2021).

About Basil D. Fossum, M.d. Pa NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

BASIL D. FOSSUM, M.D. PA (NPI 1154911527), doing business as Basil D. Fossum, M.d., is a healthcare organization registered as an urology in Fort Walton Beach, Florida and active in the NPI registry since January 2021. The organization holds a CLIA Microscopy certificate valid through June 29, 2027 and lists Basil Duane Fossum Md Pa, Owner, as its authorized official.

NPPES Registry Identity

NPI1154911527
Entity TypeOrganization
Primary Taxonomy208800000X
Legal Business NameBASIL D. FOSSUM, M.D. PA
Location Address914 MAR WALT DR STE BFort Walton Beach, FL 32547-6706
Mailing Address914 Mar Walt Dr Ste BFort Walton Beach, FL 32547-6706 · (850) 862-2555
Phone(850) 226-6572
Fax(850) 862-8564
Organization SubpartNo
Authorized OfficialBasil Duane Fossum Md PaOwner · (850) 862-2555
Enumeration DateJanuary 20, 2021
Last NPPES UpdateMay 22, 20253 updates tracked since enumeration
NPPES CertifiedMarch 31, 2021
✔ NPI 1154911527 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyUrologyAllopathic & Osteopathic Physicians
Taxonomy Code208800000X
Definition
A urologist manages benign and malignant medical and surgical disorders of the genitourinary system and the adrenal gland. This specialist has comprehensive knowledge of and skills in endoscopic, percutaneous and open surgery of congenital and acquired conditions of the urinary and reproductive systems and their contiguous structures.
914 MAR WALT DR STE B, Fort Walton Beach, FL 32547
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Other Names 1

Doing Business AsBasil D. Fossum, M.d.

Other Identifiers 1

OtherME53505FL · Medical License

Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate for Provider-Performed Microscopy Procedures (PPMP) 10D2284940

Basil D Fossum MD PA · Fort Walton Beach, FL
Active · expires Jun 29, 2027
CLIA Number10D2284940
Laboratory TypePhysician Office
Certificate Effective DateJune 30, 2025
Certificate Expiration DateJune 29, 2027
Laboratory DirectorBasil D. Fossum
Laboratory Phone(850) 862-2555
Laboratory LocationBasil D Fossum MD PA914-B Marwalt Dr, Fort Walton Beach, FL 32547
CLIA data matches this NPI record on: Phone
This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.

Other Providers at the Same Location NPPES

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

BASIL D. FOSSUM, M.D., F.A.C.S.
Urology
914 MAR WALT DR STE B
FORT WALTON BEACH, FL 32547
Okaloosa County (850) 266-5722

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Basil D. Fossum, M.D. PA's NPI number?

The NPI number for Basil D. Fossum, M.D. PA is 1154911527. It was assigned to this organization in the NPPES registry on January 20, 2021. The provider is doing business as Basil D. Fossum, M.D..

Where is Basil D. Fossum, M.D. PA located?

Basil D. Fossum, M.D. PA is located at 914 Mar Walt Dr Ste B, Fort Walton Beach, FL 32547. The listed phone number is (850) 226-6572.

What is Basil D. Fossum, M.D. PA's specialty?

The primary specialty registered for this NPI is Urology with taxonomy code 208800000X.

Does Basil D. Fossum, M.D. PA hold a CLIA laboratory certificate?

Yes. A Certificate for Provider-Performed Microscopy Procedures (PPMP) (number 10D2284940) is associated with this NPI, valid through June 29, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Basil D. Fossum, M.D. PA was last updated on May 22, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 14 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.