| National Provider Identifier [NPI]: | 1508831413 |
| Last Name Of The Provider | FANNEY |
| First Name Of The Provider | DALE |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 160 VALLEY DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | LODI |
| Zip Code Of The Provider | 535551464 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 132 |
| Number Of Services | 2507 |
| Number Of Medicare Beneficiaries | 355 |
| Total Submitted Charge Amount | 276946.25 |
| Total Medicare Allowed Amount | 77948.07 |
| Total Medicare Payment Amount | 55594.15 |
| Total Medicare Standardized Payment Amount | 58276.81 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 15 |
| Number Of Drug Services | 212 |
| Number Of Medicare Beneficiaries With Drug Services | 150 |
| Total Drug Submitted ChargeAmount | 6048 |
| Total Drug Medicare AllowedAmount | 4354.52 |
| Total Drug Medicare PaymentAmount | 4230.74 |
| Total Drug Medicare Standardized Payment Amount | 4230.74 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 117 |
| Number Of Medical Services | 2295 |
| Number Of Medicare Beneficiaries With Medical Services | 355 |
| Total Medical Submitted Charge Amount | 270898.25 |
| Total Medical Medicare Allowed Amount | 73593.55 |
| Total Medical Medicare Payment Amount | 51363.41 |
| Total Medical Medicare Standardized Payment Amount | 54046.07 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 35 |
| Number Of Beneficiaries Age 65 to 74 | 146 |
| Number Of Beneficiaries Age 75 to 84 | 102 |
| Number Of Beneficiaries Age Greater 84 | 72 |
| Number Of Female Beneficiaries | 166 |
| Number Of Male Beneficiaries | 189 |
| 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 | 295 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 60 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 3 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 12 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 19 |
| Percent Of With Hyperlipidemia | 25 |
| Percent Of With Hypertension | 34 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 27 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9738 |