| National Provider Identifier [NPI]: | 1700853637 |
| Last Name Of The Provider | JACK |
| First Name Of The Provider | COLIN |
| Middle Initial Of The Provider | N |
| Credentials Of The Provider | O.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2101 BURLINGTON BEACH RD. |
| Street Address 2 Of The Provider | SUITE D |
| City Of The Provider | VALPARAISO |
| Zip Code Of The Provider | 463830000 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Optometry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 16 |
| Number Of Services | 575 |
| Number Of Medicare Beneficiaries | 391 |
| Total Submitted Charge Amount | 52985 |
| Total Medicare Allowed Amount | 48300.37 |
| Total Medicare Payment Amount | 31242.66 |
| Total Medicare Standardized Payment Amount | 34030.47 |
| 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 | 16 |
| Number Of Medical Services | 575 |
| Number Of Medicare Beneficiaries With Medical Services | 391 |
| Total Medical Submitted Charge Amount | 52985 |
| Total Medical Medicare Allowed Amount | 48300.37 |
| Total Medical Medicare Payment Amount | 31242.66 |
| Total Medical Medicare Standardized Payment Amount | 34030.47 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 55 |
| Number Of Beneficiaries Age 65 to 74 | 192 |
| Number Of Beneficiaries Age 75 to 84 | 105 |
| Number Of Beneficiaries Age Greater 84 | 39 |
| Number Of Female Beneficiaries | 246 |
| Number Of Male Beneficiaries | 145 |
| Number Of Non Hispanic White Beneficiaries | 360 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 14 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 328 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 63 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 14 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 51 |
| Percent Of With Hypertension | 58 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 0.9626 |