| National Provider Identifier [NPI]: | 1871741124 |
| Last Name Of The Provider | LARSON |
| First Name Of The Provider | ETHAN |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1501 N CAMPBELL AVE RM 5334 |
| Street Address 2 Of The Provider | BOX 245062 |
| City Of The Provider | TUCSON |
| Zip Code Of The Provider | 857245062 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Plastic and Reconstructive Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 59 |
| Number Of Services | 198 |
| Number Of Medicare Beneficiaries | 82 |
| Total Submitted Charge Amount | 197827 |
| Total Medicare Allowed Amount | 49305.9 |
| Total Medicare Payment Amount | 38217.67 |
| Total Medicare Standardized Payment Amount | 33802.46 |
| 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 | 59 |
| Number Of Medical Services | 198 |
| Number Of Medicare Beneficiaries With Medical Services | 82 |
| Total Medical Submitted Charge Amount | 197827 |
| Total Medical Medicare Allowed Amount | 49305.9 |
| Total Medical Medicare Payment Amount | 38217.67 |
| Total Medical Medicare Standardized Payment Amount | 33802.46 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 21 |
| Number Of Beneficiaries Age 65 to 74 | 49 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 65 |
| Number Of Male Beneficiaries | 17 |
| Number Of Non Hispanic White Beneficiaries | 60 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 11 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 64 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 18 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 51 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 16 |
| Percent Of With Hyperlipidemia | 44 |
| Percent Of With Hypertension | 49 |
| Percent Of With Ischemic Heart Disease | 16 |
| Percent Of With Osteoporosis | 23 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1867 |