| National Provider Identifier [NPI]: | 1831427160 |
| Last Name Of The Provider | SOUTHAM |
| First Name Of The Provider | BRANT |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | O.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 123 HOSPITAL WAY |
| Street Address 2 Of The Provider | |
| City Of The Provider | BREWSTER |
| Zip Code Of The Provider | 98812 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Optometry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 25 |
| Number Of Services | 2026 |
| Number Of Medicare Beneficiaries | 378 |
| Total Submitted Charge Amount | 130642.35 |
| Total Medicare Allowed Amount | 129651.15 |
| Total Medicare Payment Amount | 98566.4 |
| Total Medicare Standardized Payment Amount | 95146.23 |
| 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 | 25 |
| Number Of Medical Services | 2026 |
| Number Of Medicare Beneficiaries With Medical Services | 378 |
| Total Medical Submitted Charge Amount | 130642.35 |
| Total Medical Medicare Allowed Amount | 129651.15 |
| Total Medical Medicare Payment Amount | 98566.4 |
| Total Medical Medicare Standardized Payment Amount | 95146.23 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 18 |
| Number Of Beneficiaries Age 65 to 74 | 184 |
| Number Of Beneficiaries Age 75 to 84 | 113 |
| Number Of Beneficiaries Age Greater 84 | 63 |
| Number Of Female Beneficiaries | 222 |
| Number Of Male Beneficiaries | 156 |
| Number Of Non Hispanic White Beneficiaries | 353 |
| Number Of Black or African American Beneficiaries | |
| 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 | 359 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 6 |
| Percent Of With Depression | 11 |
| Percent Of With Diabetes | 17 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 51 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 29 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 0.9441 |