| National Provider Identifier [NPI]: | 1124107917 |
| Last Name Of The Provider | SHAMPO |
| First Name Of The Provider | DALE |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1721 S STEPHENSON AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | IRON MOUNTAIN |
| Zip Code Of The Provider | 498013637 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 101 |
| Number Of Services | 943 |
| Number Of Medicare Beneficiaries | 504 |
| Total Submitted Charge Amount | 106635 |
| Total Medicare Allowed Amount | 27797.72 |
| Total Medicare Payment Amount | 17045.65 |
| Total Medicare Standardized Payment Amount | 17838.04 |
| 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 | 101 |
| Number Of Medical Services | 943 |
| Number Of Medicare Beneficiaries With Medical Services | 504 |
| Total Medical Submitted Charge Amount | 106635 |
| Total Medical Medicare Allowed Amount | 27797.72 |
| Total Medical Medicare Payment Amount | 17045.65 |
| Total Medical Medicare Standardized Payment Amount | 17838.04 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 94 |
| Number Of Beneficiaries Age 65 to 74 | 183 |
| Number Of Beneficiaries Age 75 to 84 | 149 |
| Number Of Beneficiaries Age Greater 84 | 78 |
| Number Of Female Beneficiaries | 324 |
| Number Of Male Beneficiaries | 180 |
| 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 | 389 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 115 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 29 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 54 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 41 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.4017 |