| National Provider Identifier [NPI]: | 1356367494 |
| Last Name Of The Provider | FORM |
| First Name Of The Provider | JACOB |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | D.P.M. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4129 FRANKLIN WAY |
| Street Address 2 Of The Provider | |
| City Of The Provider | LAFAYETTE HILL |
| Zip Code Of The Provider | 194441300 |
| State Code Of The Provider | PA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Podiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 16 |
| Number Of Services | 4981 |
| Number Of Medicare Beneficiaries | 1443 |
| Total Submitted Charge Amount | 228961 |
| Total Medicare Allowed Amount | 222328.71 |
| Total Medicare Payment Amount | 173004.79 |
| Total Medicare Standardized Payment Amount | 166245.54 |
| 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 | 16 |
| Number Of Medical Services | 4981 |
| Number Of Medicare Beneficiaries With Medical Services | 1443 |
| Total Medical Submitted Charge Amount | 228961 |
| Total Medical Medicare Allowed Amount | 222328.71 |
| Total Medical Medicare Payment Amount | 173004.79 |
| Total Medical Medicare Standardized Payment Amount | 166245.54 |
| Average Age Of Beneficiaries | 79 |
| Number Of Beneficiaries Age Less65 | 142 |
| Number Of Beneficiaries Age 65 to 74 | 338 |
| Number Of Beneficiaries Age 75 to 84 | 413 |
| Number Of Beneficiaries Age Greater 84 | 550 |
| Number Of Female Beneficiaries | 905 |
| Number Of Male Beneficiaries | 538 |
| Number Of Non Hispanic White Beneficiaries | 433 |
| Number Of Black or African American Beneficiaries | 946 |
| 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 | 322 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 1121 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 73 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 56 |
| Percent Of With Chronic Kidney Disease | 43 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 43 |
| Percent Of With Diabetes | 60 |
| Percent Of With Hyperlipidemia | 49 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 60 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 22 |
| Percent Of With Stroke | 21 |
| Average HCC Risk Score Of Beneficiaries | 2.4966 |