| National Provider Identifier [NPI]: | 1073563847 |
| Last Name Of The Provider | CLARK |
| 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 | 1528 DEL PRADO BLVD S |
| Street Address 2 Of The Provider | |
| City Of The Provider | CAPE CORAL |
| Zip Code Of The Provider | 339903798 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Rheumatology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 94 |
| Number Of Services | 4727 |
| Number Of Medicare Beneficiaries | 680 |
| Total Submitted Charge Amount | 589128.5 |
| Total Medicare Allowed Amount | 280215.36 |
| Total Medicare Payment Amount | 201383.58 |
| Total Medicare Standardized Payment Amount | 193979.41 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 1429 |
| Number Of Medicare Beneficiaries With Drug Services | 187 |
| Total Drug Submitted ChargeAmount | 19989.5 |
| Total Drug Medicare AllowedAmount | 9783.49 |
| Total Drug Medicare PaymentAmount | 7609.63 |
| Total Drug Medicare Standardized Payment Amount | 7609.63 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 84 |
| Number Of Medical Services | 3298 |
| Number Of Medicare Beneficiaries With Medical Services | 680 |
| Total Medical Submitted Charge Amount | 569139 |
| Total Medical Medicare Allowed Amount | 270431.87 |
| Total Medical Medicare Payment Amount | 193773.95 |
| Total Medical Medicare Standardized Payment Amount | 186369.78 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 97 |
| Number Of Beneficiaries Age 65 to 74 | 318 |
| Number Of Beneficiaries Age 75 to 84 | 205 |
| Number Of Beneficiaries Age Greater 84 | 60 |
| Number Of Female Beneficiaries | 456 |
| Number Of Male Beneficiaries | 224 |
| Number Of Non Hispanic White Beneficiaries | 617 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 41 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 604 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 76 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 21 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.2235 |