| National Provider Identifier [NPI]: | 1649255464 |
| Last Name Of The Provider | LIEBO |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3931 LOUISIANA AVE S |
| Street Address 2 Of The Provider | STE E400 |
| City Of The Provider | ST LOUIS PARK |
| Zip Code Of The Provider | 554264375 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Sports Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 33 |
| Number Of Services | 290 |
| Number Of Medicare Beneficiaries | 94 |
| Total Submitted Charge Amount | 28876.75 |
| Total Medicare Allowed Amount | 11309.48 |
| Total Medicare Payment Amount | 7646.65 |
| Total Medicare Standardized Payment Amount | 7768.46 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 101 |
| Number Of Medicare Beneficiaries With Drug Services | 23 |
| Total Drug Submitted ChargeAmount | 1996 |
| Total Drug Medicare AllowedAmount | 777.32 |
| Total Drug Medicare PaymentAmount | 590.42 |
| Total Drug Medicare Standardized Payment Amount | 590.42 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 29 |
| Number Of Medical Services | 189 |
| Number Of Medicare Beneficiaries With Medical Services | 94 |
| Total Medical Submitted Charge Amount | 26880.75 |
| Total Medical Medicare Allowed Amount | 10532.16 |
| Total Medical Medicare Payment Amount | 7056.23 |
| Total Medical Medicare Standardized Payment Amount | 7178.04 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 32 |
| Number Of Beneficiaries Age 65 to 74 | 18 |
| Number Of Beneficiaries Age 75 to 84 | 30 |
| Number Of Beneficiaries Age Greater 84 | 14 |
| Number Of Female Beneficiaries | 56 |
| Number Of Male Beneficiaries | 38 |
| Number Of Non Hispanic White Beneficiaries | 78 |
| 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 | 64 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 30 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 15 |
| Percent Of With Asthma | 16 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 23 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 34 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 60 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.5685 |