| National Provider Identifier [NPI]: | 1114197142 |
| Last Name Of The Provider | FORTMANN |
| First Name Of The Provider | DANIEL |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 32281 CAMINO CAPISTRANO |
| Street Address 2 Of The Provider | SUITE C-102 |
| City Of The Provider | SAN JUAN CAPISTRANO |
| Zip Code Of The Provider | 926753784 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 22 |
| Number Of Services | 715 |
| Number Of Medicare Beneficiaries | 159 |
| Total Submitted Charge Amount | 89420 |
| Total Medicare Allowed Amount | 54501.21 |
| Total Medicare Payment Amount | 41689.25 |
| Total Medicare Standardized Payment Amount | 37279.53 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 70 |
| Number Of Medicare Beneficiaries With Drug Services | 67 |
| Total Drug Submitted ChargeAmount | 2905 |
| Total Drug Medicare AllowedAmount | 1451.38 |
| Total Drug Medicare PaymentAmount | 1422.22 |
| Total Drug Medicare Standardized Payment Amount | 1422.22 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 18 |
| Number Of Medical Services | 645 |
| Number Of Medicare Beneficiaries With Medical Services | 159 |
| Total Medical Submitted Charge Amount | 86515 |
| Total Medical Medicare Allowed Amount | 53049.83 |
| Total Medical Medicare Payment Amount | 40267.03 |
| Total Medical Medicare Standardized Payment Amount | 35857.31 |
| Average Age Of Beneficiaries | 79 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 51 |
| Number Of Beneficiaries Age 75 to 84 | 61 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 79 |
| Number Of Male Beneficiaries | 80 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 16 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 12 |
| Percent Of With Diabetes | 11 |
| Percent Of With Hyperlipidemia | 75 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 18 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.1332 |