| National Provider Identifier [NPI]: | 1336211549 |
| Last Name Of The Provider | FORTMAN |
| First Name Of The Provider | CARRIE |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | PAC |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 501 THORNHILL DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | CAROL STREAM |
| Zip Code Of The Provider | 601882793 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 27 |
| Number Of Services | 1148 |
| Number Of Medicare Beneficiaries | 371 |
| Total Submitted Charge Amount | 81043.35 |
| Total Medicare Allowed Amount | 35828.44 |
| Total Medicare Payment Amount | 27284.31 |
| Total Medicare Standardized Payment Amount | 30736.52 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 23 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 1215.35 |
| Total Drug Medicare AllowedAmount | 573.83 |
| Total Drug Medicare PaymentAmount | 524 |
| Total Drug Medicare Standardized Payment Amount | 524 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 22 |
| Number Of Medical Services | 1125 |
| Number Of Medicare Beneficiaries With Medical Services | 371 |
| Total Medical Submitted Charge Amount | 79828 |
| Total Medical Medicare Allowed Amount | 35254.61 |
| Total Medical Medicare Payment Amount | 26760.31 |
| Total Medical Medicare Standardized Payment Amount | 30212.52 |
| Average Age Of Beneficiaries | 77 |
| Number Of Beneficiaries Age Less65 | 18 |
| Number Of Beneficiaries Age 65 to 74 | 132 |
| Number Of Beneficiaries Age 75 to 84 | 137 |
| Number Of Beneficiaries Age Greater 84 | 84 |
| Number Of Female Beneficiaries | 237 |
| Number Of Male Beneficiaries | 134 |
| Number Of Non Hispanic White Beneficiaries | 335 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 20 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 330 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 41 |
| Percent Of With Atrial Fibrillation | 21 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 12 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.0957 |