| National Provider Identifier [NPI]: | 1235349473 |
| Last Name Of The Provider | SUHARDJA |
| First Name Of The Provider | AGUSTINUS |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 401 E SPRUCE ST |
| Street Address 2 Of The Provider | ST. CATHERINE HOSP. RADIOLOGY DEPT. |
| City Of The Provider | GARDEN CITY |
| Zip Code Of The Provider | 678465679 |
| State Code Of The Provider | KS |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 202 |
| Number Of Services | 5393 |
| Number Of Medicare Beneficiaries | 2256 |
| Total Submitted Charge Amount | 542125 |
| Total Medicare Allowed Amount | 168228.5 |
| Total Medicare Payment Amount | 124550.8 |
| Total Medicare Standardized Payment Amount | 131856.11 |
| 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 | 202 |
| Number Of Medical Services | 5393 |
| Number Of Medicare Beneficiaries With Medical Services | 2256 |
| Total Medical Submitted Charge Amount | 542125 |
| Total Medical Medicare Allowed Amount | 168228.5 |
| Total Medical Medicare Payment Amount | 124550.8 |
| Total Medical Medicare Standardized Payment Amount | 131856.11 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 375 |
| Number Of Beneficiaries Age 65 to 74 | 810 |
| Number Of Beneficiaries Age 75 to 84 | 685 |
| Number Of Beneficiaries Age Greater 84 | 386 |
| Number Of Female Beneficiaries | 1350 |
| Number Of Male Beneficiaries | 906 |
| Number Of Non Hispanic White Beneficiaries | 1902 |
| Number Of Black or African American Beneficiaries | 18 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 296 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 17 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1740 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 516 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 15 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 27 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.3097 |