| National Provider Identifier [NPI]: | 1114199197 |
| Last Name Of The Provider | BOULTER |
| First Name Of The Provider | DANIEL |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 395 W 12TH AVE |
| Street Address 2 Of The Provider | RM 460 |
| City Of The Provider | COLUMBUS |
| Zip Code Of The Provider | 432101267 |
| State Code Of The Provider | OH |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 48 |
| Number Of Services | 2248 |
| Number Of Medicare Beneficiaries | 960 |
| Total Submitted Charge Amount | 502620 |
| Total Medicare Allowed Amount | 106349.28 |
| Total Medicare Payment Amount | 81638.05 |
| Total Medicare Standardized Payment Amount | 81638.43 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 922 |
| Number Of Medicare Beneficiaries With Drug Services | 35 |
| Total Drug Submitted ChargeAmount | 4802 |
| Total Drug Medicare AllowedAmount | 1024.32 |
| Total Drug Medicare PaymentAmount | 786.09 |
| Total Drug Medicare Standardized Payment Amount | 786.09 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 46 |
| Number Of Medical Services | 1326 |
| Number Of Medicare Beneficiaries With Medical Services | 960 |
| Total Medical Submitted Charge Amount | 497818 |
| Total Medical Medicare Allowed Amount | 105324.96 |
| Total Medical Medicare Payment Amount | 80851.96 |
| Total Medical Medicare Standardized Payment Amount | 80852.34 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 296 |
| Number Of Beneficiaries Age 65 to 74 | 353 |
| Number Of Beneficiaries Age 75 to 84 | 217 |
| Number Of Beneficiaries Age Greater 84 | 94 |
| Number Of Female Beneficiaries | 476 |
| Number Of Male Beneficiaries | 484 |
| Number Of Non Hispanic White Beneficiaries | 786 |
| Number Of Black or African American Beneficiaries | 123 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 18 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 17 |
| Number Of Beneficiaries With Medicare Only Entitlement | 635 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 325 |
| Percent Of With Atrial Fibrillation | 16 |
| Percent Of With Alzheimers Disease or Dementia | 20 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 19 |
| Percent Of With Heart Failure | 29 |
| Percent Of With Chronic Kidney Disease | 38 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 45 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 46 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 25 |
| Average HCC Risk Score Of Beneficiaries | 2.0322 |