| National Provider Identifier [NPI]: | 1649456682 |
| Last Name Of The Provider | LY |
| First Name Of The Provider | CONG |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 18685 MAIN ST, PMB 176 |
| Street Address 2 Of The Provider | STE 101 |
| City Of The Provider | HUNTINGTON BEACH |
| Zip Code Of The Provider | 92648 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 48 |
| Number Of Services | 709 |
| Number Of Medicare Beneficiaries | 362 |
| Total Submitted Charge Amount | 274726 |
| Total Medicare Allowed Amount | 65641.17 |
| Total Medicare Payment Amount | 50774.38 |
| Total Medicare Standardized Payment Amount | 48056.91 |
| 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 | 48 |
| Number Of Medical Services | 709 |
| Number Of Medicare Beneficiaries With Medical Services | 362 |
| Total Medical Submitted Charge Amount | 274726 |
| Total Medical Medicare Allowed Amount | 65641.17 |
| Total Medical Medicare Payment Amount | 50774.38 |
| Total Medical Medicare Standardized Payment Amount | 48056.91 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 116 |
| Number Of Beneficiaries Age 65 to 74 | 79 |
| Number Of Beneficiaries Age 75 to 84 | 94 |
| Number Of Beneficiaries Age Greater 84 | 73 |
| Number Of Female Beneficiaries | 201 |
| Number Of Male Beneficiaries | 161 |
| Number Of Non Hispanic White Beneficiaries | 189 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 68 |
| Number Of Hispanic Beneficiaries | 65 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 117 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 245 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 42 |
| Percent Of With Asthma | 21 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 46 |
| Percent Of With Chronic Kidney Disease | 54 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 42 |
| Percent Of With Depression | 48 |
| Percent Of With Diabetes | 54 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 60 |
| Percent Of With Osteoporosis | 19 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 47 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 34 |
| Percent Of With Stroke | 14 |
| Average HCC Risk Score Of Beneficiaries | 3.0577 |