| National Provider Identifier [NPI]: | 1639287766 |
| Last Name Of The Provider | WILSON |
| First Name Of The Provider | CARRIE |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6801 S BENNETT AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606491501 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 13 |
| Number Of Services | 313 |
| Number Of Medicare Beneficiaries | 265 |
| Total Submitted Charge Amount | 198032 |
| Total Medicare Allowed Amount | 47205.78 |
| Total Medicare Payment Amount | 36305.67 |
| Total Medicare Standardized Payment Amount | 33525.68 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 13 |
| Number Of Medical Services | 313 |
| Number Of Medicare Beneficiaries With Medical Services | 265 |
| Total Medical Submitted Charge Amount | 198032 |
| Total Medical Medicare Allowed Amount | 47205.78 |
| Total Medical Medicare Payment Amount | 36305.67 |
| Total Medical Medicare Standardized Payment Amount | 33525.68 |
| Average Age Of Beneficiaries | 61 |
| Number Of Beneficiaries Age Less65 | 138 |
| Number Of Beneficiaries Age 65 to 74 | 70 |
| Number Of Beneficiaries Age 75 to 84 | 30 |
| Number Of Beneficiaries Age Greater 84 | 27 |
| Number Of Female Beneficiaries | 121 |
| Number Of Male Beneficiaries | 144 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | 218 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 49 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 216 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 26 |
| Percent Of With Asthma | 34 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 48 |
| Percent Of With Chronic Kidney Disease | 44 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 37 |
| Percent Of With Depression | 45 |
| Percent Of With Diabetes | 57 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 62 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 60 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 35 |
| Percent Of With Stroke | 12 |
| Average HCC Risk Score Of Beneficiaries | 2.5558 |