| National Provider Identifier [NPI]: | 1174569107 |
| Last Name Of The Provider | FULLER |
| First Name Of The Provider | GREGORY |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1006 AIRPORT RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | JACKSON |
| Zip Code Of The Provider | 492021851 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 12 |
| Number Of Services | 581 |
| Number Of Medicare Beneficiaries | 407 |
| Total Submitted Charge Amount | 328057 |
| Total Medicare Allowed Amount | 62016.17 |
| Total Medicare Payment Amount | 47847.68 |
| Total Medicare Standardized Payment Amount | 48560.5 |
| 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 | 12 |
| Number Of Medical Services | 581 |
| Number Of Medicare Beneficiaries With Medical Services | 407 |
| Total Medical Submitted Charge Amount | 328057 |
| Total Medical Medicare Allowed Amount | 62016.17 |
| Total Medical Medicare Payment Amount | 47847.68 |
| Total Medical Medicare Standardized Payment Amount | 48560.5 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 120 |
| Number Of Beneficiaries Age 65 to 74 | 98 |
| Number Of Beneficiaries Age 75 to 84 | 97 |
| Number Of Beneficiaries Age Greater 84 | 92 |
| Number Of Female Beneficiaries | 242 |
| Number Of Male Beneficiaries | 165 |
| Number Of Non Hispanic White Beneficiaries | 335 |
| Number Of Black or African American Beneficiaries | 52 |
| 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 | 250 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 157 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 29 |
| Percent Of With Asthma | 16 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 42 |
| Percent Of With Chronic Kidney Disease | 37 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 32 |
| Percent Of With Depression | 45 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 53 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 51 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 11 |
| Percent Of With Stroke | 12 |
| Average HCC Risk Score Of Beneficiaries | 1.9159 |