| National Provider Identifier [NPI]: | 1164450961 |
| Last Name Of The Provider | DAVID |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | F |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 5102 W CAMPBELL AVE |
| Street Address 2 Of The Provider | EMERGENCY DEPARTMENT |
| City Of The Provider | PHOENIX |
| Zip Code Of The Provider | 850311703 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 17 |
| Number Of Services | 242 |
| Number Of Medicare Beneficiaries | 137 |
| Total Submitted Charge Amount | 215255 |
| Total Medicare Allowed Amount | 25629.78 |
| Total Medicare Payment Amount | 19829.29 |
| Total Medicare Standardized Payment Amount | 19846.73 |
| 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 | 17 |
| Number Of Medical Services | 242 |
| Number Of Medicare Beneficiaries With Medical Services | 137 |
| Total Medical Submitted Charge Amount | 215255 |
| Total Medical Medicare Allowed Amount | 25629.78 |
| Total Medical Medicare Payment Amount | 19829.29 |
| Total Medical Medicare Standardized Payment Amount | 19846.73 |
| Average Age Of Beneficiaries | 61 |
| Number Of Beneficiaries Age Less65 | 74 |
| Number Of Beneficiaries Age 65 to 74 | 34 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 71 |
| Number Of Male Beneficiaries | 66 |
| Number Of Non Hispanic White Beneficiaries | 68 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 38 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 47 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 90 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 19 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 32 |
| Percent Of With Chronic Kidney Disease | 42 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 29 |
| Percent Of With Depression | 35 |
| Percent Of With Diabetes | 44 |
| Percent Of With Hyperlipidemia | 45 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 15 |
| Percent Of With Stroke | 13 |
| Average HCC Risk Score Of Beneficiaries | 2.381 |