| National Provider Identifier [NPI]: | 1558523795 |
| Last Name Of The Provider | CLARK |
| First Name Of The Provider | HEATHER |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2200 RANDALLIA DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468054638 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 19 |
| Number Of Services | 883 |
| Number Of Medicare Beneficiaries | 445 |
| Total Submitted Charge Amount | 505803 |
| Total Medicare Allowed Amount | 72308.89 |
| Total Medicare Payment Amount | 54413.85 |
| Total Medicare Standardized Payment Amount | 56548.72 |
| 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 | 19 |
| Number Of Medical Services | 883 |
| Number Of Medicare Beneficiaries With Medical Services | 445 |
| Total Medical Submitted Charge Amount | 505803 |
| Total Medical Medicare Allowed Amount | 72308.89 |
| Total Medical Medicare Payment Amount | 54413.85 |
| Total Medical Medicare Standardized Payment Amount | 56548.72 |
| Average Age Of Beneficiaries | 64 |
| Number Of Beneficiaries Age Less65 | 194 |
| Number Of Beneficiaries Age 65 to 74 | 94 |
| Number Of Beneficiaries Age 75 to 84 | 87 |
| Number Of Beneficiaries Age Greater 84 | 70 |
| Number Of Female Beneficiaries | 275 |
| Number Of Male Beneficiaries | 170 |
| Number Of Non Hispanic White Beneficiaries | 432 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 228 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 217 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 18 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 27 |
| Percent Of With Chronic Kidney Disease | 27 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 35 |
| Percent Of With Depression | 40 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 35 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.6206 |