| National Provider Identifier [NPI]: | 1093774135 |
| Last Name Of The Provider | CLEVIDENCE |
| First Name Of The Provider | DEREK |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | MD, PHD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6408 COPPS AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MONONA |
| Zip Code Of The Provider | 537163702 |
| 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 | 85 |
| Number Of Services | 1494 |
| Number Of Medicare Beneficiaries | 307 |
| Total Submitted Charge Amount | 182111 |
| Total Medicare Allowed Amount | 60968.84 |
| Total Medicare Payment Amount | 48054.32 |
| Total Medicare Standardized Payment Amount | 50401.74 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 124 |
| Number Of Medicare Beneficiaries With Drug Services | 89 |
| Total Drug Submitted ChargeAmount | 5267 |
| Total Drug Medicare AllowedAmount | 2112.14 |
| Total Drug Medicare PaymentAmount | 2031.15 |
| Total Drug Medicare Standardized Payment Amount | 2031.15 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 75 |
| Number Of Medical Services | 1370 |
| Number Of Medicare Beneficiaries With Medical Services | 307 |
| Total Medical Submitted Charge Amount | 176844 |
| Total Medical Medicare Allowed Amount | 58856.7 |
| Total Medical Medicare Payment Amount | 46023.17 |
| Total Medical Medicare Standardized Payment Amount | 48370.59 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 45 |
| Number Of Beneficiaries Age 65 to 74 | 152 |
| Number Of Beneficiaries Age 75 to 84 | 80 |
| Number Of Beneficiaries Age Greater 84 | 30 |
| Number Of Female Beneficiaries | 192 |
| Number Of Male Beneficiaries | 115 |
| Number Of Non Hispanic White Beneficiaries | 294 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 269 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 38 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 9 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 51 |
| Percent Of With Hypertension | 58 |
| Percent Of With Ischemic Heart Disease | 21 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 0.9376 |