| National Provider Identifier [NPI]: | 1679716278 |
| Last Name Of The Provider | MORENO |
| First Name Of The Provider | ISMAEL |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3635 VISTA AT GRAND |
| Street Address 2 Of The Provider | DESLOGE TOWERS, 2ND FLOOR |
| City Of The Provider | ST. LOUIS |
| Zip Code Of The Provider | 63110 |
| State Code Of The Provider | MO |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 120 |
| Number Of Services | 569 |
| Number Of Medicare Beneficiaries | 185 |
| Total Submitted Charge Amount | 267307 |
| Total Medicare Allowed Amount | 57765.03 |
| Total Medicare Payment Amount | 44434.35 |
| Total Medicare Standardized Payment Amount | 44857.4 |
| 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 | 120 |
| Number Of Medical Services | 569 |
| Number Of Medicare Beneficiaries With Medical Services | 185 |
| Total Medical Submitted Charge Amount | 267307 |
| Total Medical Medicare Allowed Amount | 57765.03 |
| Total Medical Medicare Payment Amount | 44434.35 |
| Total Medical Medicare Standardized Payment Amount | 44857.4 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 66 |
| Number Of Beneficiaries Age 65 to 74 | 66 |
| Number Of Beneficiaries Age 75 to 84 | 39 |
| Number Of Beneficiaries Age Greater 84 | 14 |
| Number Of Female Beneficiaries | 90 |
| Number Of Male Beneficiaries | 95 |
| Number Of Non Hispanic White Beneficiaries | 112 |
| Number Of Black or African American Beneficiaries | |
| 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 | 104 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 81 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 22 |
| Percent Of With Heart Failure | 46 |
| Percent Of With Chronic Kidney Disease | 73 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 31 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 48 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 62 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 43 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 12 |
| Average HCC Risk Score Of Beneficiaries | 3.2689 |