| National Provider Identifier [NPI]: | 1790717163 |
| Last Name Of The Provider | PETERSON |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 765 LIBERTY ST |
| Street Address 2 Of The Provider | SUITE # 303 |
| City Of The Provider | MEADVILLE |
| Zip Code Of The Provider | 163352566 |
| State Code Of The Provider | PA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 836 |
| Number Of Medicare Beneficiaries | 178 |
| Total Submitted Charge Amount | 88453.38 |
| Total Medicare Allowed Amount | 62564.78 |
| Total Medicare Payment Amount | 49863.88 |
| Total Medicare Standardized Payment Amount | 52499.85 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 94 |
| Number Of Medicare Beneficiaries With Drug Services | 75 |
| Total Drug Submitted ChargeAmount | 2707.43 |
| Total Drug Medicare AllowedAmount | 1690.96 |
| Total Drug Medicare PaymentAmount | 1650.6 |
| Total Drug Medicare Standardized Payment Amount | 1650.6 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 27 |
| Number Of Medical Services | 742 |
| Number Of Medicare Beneficiaries With Medical Services | 178 |
| Total Medical Submitted Charge Amount | 85745.95 |
| Total Medical Medicare Allowed Amount | 60873.82 |
| Total Medical Medicare Payment Amount | 48213.28 |
| Total Medical Medicare Standardized Payment Amount | 50849.25 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 11 |
| Number Of Beneficiaries Age 65 to 74 | 84 |
| Number Of Beneficiaries Age 75 to 84 | 61 |
| Number Of Beneficiaries Age Greater 84 | 22 |
| Number Of Female Beneficiaries | 90 |
| Number Of Male Beneficiaries | 88 |
| Number Of Non Hispanic White Beneficiaries | 178 |
| Number Of Black or African American Beneficiaries | 0 |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 0 |
| 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 | 165 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 13 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 12 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 12 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 64 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8127 |