| National Provider Identifier [NPI]: | 1821043811 |
| Last Name Of The Provider | FOSSUM |
| First Name Of The Provider | BASIL |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | M.D., F.A.C.S. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 914B MAR WALT DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WALTON BEACH |
| Zip Code Of The Provider | 325476706 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Urology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 90 |
| Number Of Services | 15224 |
| Number Of Medicare Beneficiaries | 1301 |
| Total Submitted Charge Amount | 1630824.27 |
| Total Medicare Allowed Amount | 521780.38 |
| Total Medicare Payment Amount | 391220.32 |
| Total Medicare Standardized Payment Amount | 393951.97 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 10541 |
| Number Of Medicare Beneficiaries With Drug Services | 79 |
| Total Drug Submitted ChargeAmount | 676654.32 |
| Total Drug Medicare AllowedAmount | 221096.87 |
| Total Drug Medicare PaymentAmount | 172481.57 |
| Total Drug Medicare Standardized Payment Amount | 172481.57 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 80 |
| Number Of Medical Services | 4683 |
| Number Of Medicare Beneficiaries With Medical Services | 1301 |
| Total Medical Submitted Charge Amount | 954169.95 |
| Total Medical Medicare Allowed Amount | 300683.51 |
| Total Medical Medicare Payment Amount | 218738.75 |
| Total Medical Medicare Standardized Payment Amount | 221470.4 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 48 |
| Number Of Beneficiaries Age 65 to 74 | 479 |
| Number Of Beneficiaries Age 75 to 84 | 581 |
| Number Of Beneficiaries Age Greater 84 | 193 |
| Number Of Female Beneficiaries | 294 |
| Number Of Male Beneficiaries | 1007 |
| Number Of Non Hispanic White Beneficiaries | 1215 |
| Number Of Black or African American Beneficiaries | 42 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 23 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 1259 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 42 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 20 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 13 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 72 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 51 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.2137 |