| National Provider Identifier [NPI]: | 1104877265 |
| Last Name Of The Provider | ANON |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1645 W 8TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | ERIE |
| Zip Code Of The Provider | 165055007 |
| State Code Of The Provider | PA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Otolaryngology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 43 |
| Number Of Services | 1859 |
| Number Of Medicare Beneficiaries | 510 |
| Total Submitted Charge Amount | 143049 |
| Total Medicare Allowed Amount | 93514.35 |
| Total Medicare Payment Amount | 67312.46 |
| Total Medicare Standardized Payment Amount | 70467.31 |
| 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 | 43 |
| Number Of Medical Services | 1859 |
| Number Of Medicare Beneficiaries With Medical Services | 510 |
| Total Medical Submitted Charge Amount | 143049 |
| Total Medical Medicare Allowed Amount | 93514.35 |
| Total Medical Medicare Payment Amount | 67312.46 |
| Total Medical Medicare Standardized Payment Amount | 70467.31 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 85 |
| Number Of Beneficiaries Age 65 to 74 | 179 |
| Number Of Beneficiaries Age 75 to 84 | 151 |
| Number Of Beneficiaries Age Greater 84 | 95 |
| Number Of Female Beneficiaries | 305 |
| Number Of Male Beneficiaries | 205 |
| Number Of Non Hispanic White Beneficiaries | 490 |
| 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 | |
| Number Of Beneficiaries With Medicare Only Entitlement | 399 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 111 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 43 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.1822 |