| National Provider Identifier [NPI]: | 1578759304 |
| Last Name Of The Provider | ELLEFSEN |
| First Name Of The Provider | CODY |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 203 E DALKE AVE STE B |
| Street Address 2 Of The Provider | |
| City Of The Provider | SPOKANE |
| Zip Code Of The Provider | 992088112 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 32 |
| Number Of Services | 547 |
| Number Of Medicare Beneficiaries | 184 |
| Total Submitted Charge Amount | 64721.98 |
| Total Medicare Allowed Amount | 35219.48 |
| Total Medicare Payment Amount | 24368.81 |
| Total Medicare Standardized Payment Amount | 24970.5 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 99 |
| Number Of Medicare Beneficiaries With Drug Services | 37 |
| Total Drug Submitted ChargeAmount | 1358 |
| Total Drug Medicare AllowedAmount | 897.76 |
| Total Drug Medicare PaymentAmount | 841.25 |
| Total Drug Medicare Standardized Payment Amount | 841.25 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 23 |
| Number Of Medical Services | 448 |
| Number Of Medicare Beneficiaries With Medical Services | 184 |
| Total Medical Submitted Charge Amount | 63363.98 |
| Total Medical Medicare Allowed Amount | 34321.72 |
| Total Medical Medicare Payment Amount | 23527.56 |
| Total Medical Medicare Standardized Payment Amount | 24129.25 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 26 |
| Number Of Beneficiaries Age 65 to 74 | 84 |
| Number Of Beneficiaries Age 75 to 84 | 49 |
| Number Of Beneficiaries Age Greater 84 | 25 |
| Number Of Female Beneficiaries | 91 |
| Number Of Male Beneficiaries | 93 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 161 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 23 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.948 |