| National Provider Identifier [NPI]: | 1902992837 |
| Last Name Of The Provider | CLARK |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | O |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 166 S 5TH ST |
| Street Address 2 Of The Provider | SUITE B |
| City Of The Provider | MONTPELIER |
| Zip Code Of The Provider | 832541557 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 21 |
| Number Of Services | 228 |
| Number Of Medicare Beneficiaries | 75 |
| Total Submitted Charge Amount | 58204.36 |
| Total Medicare Allowed Amount | 26104.75 |
| Total Medicare Payment Amount | 20351.01 |
| Total Medicare Standardized Payment Amount | 21401.23 |
| 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 | 21 |
| Number Of Medical Services | 228 |
| Number Of Medicare Beneficiaries With Medical Services | 75 |
| Total Medical Submitted Charge Amount | 58204.36 |
| Total Medical Medicare Allowed Amount | 26104.75 |
| Total Medical Medicare Payment Amount | 20351.01 |
| Total Medical Medicare Standardized Payment Amount | 21401.23 |
| Average Age Of Beneficiaries | 77 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 24 |
| Number Of Beneficiaries Age 75 to 84 | 24 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 39 |
| Number Of Male Beneficiaries | 36 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 56 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | 25 |
| Percent Of With Alzheimers Disease or Dementia | 23 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 16 |
| Percent Of With Heart Failure | 48 |
| Percent Of With Chronic Kidney Disease | 41 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 25 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 37 |
| Percent Of With Hyperlipidemia | 40 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 41 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 56 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 29 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.9538 |