| National Provider Identifier [NPI]: | 1114960473 |
| Last Name Of The Provider | FORTENBERRY |
| First Name Of The Provider | DEWITT |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2602 SAINT MICHAEL DR |
| Street Address 2 Of The Provider | SUITE 302 |
| City Of The Provider | TEXARKANA |
| Zip Code Of The Provider | 755032387 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 20 |
| Number Of Services | 2068 |
| Number Of Medicare Beneficiaries | 390 |
| Total Submitted Charge Amount | 380737.7 |
| Total Medicare Allowed Amount | 213402.66 |
| Total Medicare Payment Amount | 166104.66 |
| Total Medicare Standardized Payment Amount | 138481.33 |
| 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 | 20 |
| Number Of Medical Services | 2068 |
| Number Of Medicare Beneficiaries With Medical Services | 390 |
| Total Medical Submitted Charge Amount | 380737.7 |
| Total Medical Medicare Allowed Amount | 213402.66 |
| Total Medical Medicare Payment Amount | 166104.66 |
| Total Medical Medicare Standardized Payment Amount | 138481.33 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 79 |
| Number Of Beneficiaries Age 65 to 74 | 128 |
| Number Of Beneficiaries Age 75 to 84 | 113 |
| Number Of Beneficiaries Age Greater 84 | 70 |
| Number Of Female Beneficiaries | 202 |
| Number Of Male Beneficiaries | 188 |
| Number Of Non Hispanic White Beneficiaries | 300 |
| Number Of Black or African American Beneficiaries | 69 |
| 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 | 241 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 149 |
| Percent Of With Atrial Fibrillation | 23 |
| Percent Of With Alzheimers Disease or Dementia | 31 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 55 |
| Percent Of With Chronic Kidney Disease | 49 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 48 |
| Percent Of With Depression | 39 |
| Percent Of With Diabetes | 48 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 69 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 51 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 17 |
| Percent Of With Stroke | 20 |
| Average HCC Risk Score Of Beneficiaries | 2.1147 |