| National Provider Identifier [NPI]: | 1215042361 |
| Last Name Of The Provider | FORMAN |
| First Name Of The Provider | EVGENIA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2216 DORCHESTER AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | DORCHESTER CENTER |
| Zip Code Of The Provider | 021245607 |
| State Code Of The Provider | MA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Geriatric Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 13 |
| Number Of Services | 1627 |
| Number Of Medicare Beneficiaries | 433 |
| Total Submitted Charge Amount | 391333 |
| Total Medicare Allowed Amount | 159619.53 |
| Total Medicare Payment Amount | 119533.2 |
| Total Medicare Standardized Payment Amount | 118463.06 |
| 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 | 13 |
| Number Of Medical Services | 1627 |
| Number Of Medicare Beneficiaries With Medical Services | 433 |
| Total Medical Submitted Charge Amount | 391333 |
| Total Medical Medicare Allowed Amount | 159619.53 |
| Total Medical Medicare Payment Amount | 119533.2 |
| Total Medical Medicare Standardized Payment Amount | 118463.06 |
| Average Age Of Beneficiaries | 78 |
| Number Of Beneficiaries Age Less65 | 68 |
| Number Of Beneficiaries Age 65 to 74 | 98 |
| Number Of Beneficiaries Age 75 to 84 | 116 |
| Number Of Beneficiaries Age Greater 84 | 151 |
| Number Of Female Beneficiaries | 273 |
| Number Of Male Beneficiaries | 160 |
| Number Of Non Hispanic White Beneficiaries | 305 |
| Number Of Black or African American Beneficiaries | 71 |
| Number Of AsianPacific Islander Beneficiaries | 24 |
| Number Of Hispanic Beneficiaries | 22 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 11 |
| Number Of Beneficiaries With Medicare Only Entitlement | 157 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 276 |
| Percent Of With Atrial Fibrillation | 22 |
| Percent Of With Alzheimers Disease or Dementia | 45 |
| Percent Of With Asthma | 18 |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 49 |
| Percent Of With Chronic Kidney Disease | 57 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 61 |
| Percent Of With Diabetes | 46 |
| Percent Of With Hyperlipidemia | 62 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 50 |
| Percent Of With Osteoporosis | 24 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 54 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 22 |
| Percent Of With Stroke | 15 |
| Average HCC Risk Score Of Beneficiaries | 2.8093 |