| National Provider Identifier [NPI]: | 1053318618 |
| Last Name Of The Provider | NISSEN |
| First Name Of The Provider | JACQUELINE |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 263 FARMINGTON AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | FARMINGTON |
| Zip Code Of The Provider | 060301921 |
| State Code Of The Provider | CT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 16 |
| Number Of Services | 89 |
| Number Of Medicare Beneficiaries | 28 |
| Total Submitted Charge Amount | 13300 |
| Total Medicare Allowed Amount | 7504.35 |
| Total Medicare Payment Amount | 5923.54 |
| Total Medicare Standardized Payment Amount | 5538.13 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 12 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 950 |
| Total Drug Medicare AllowedAmount | 530.16 |
| Total Drug Medicare PaymentAmount | 519.12 |
| Total Drug Medicare Standardized Payment Amount | 519.12 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 12 |
| Number Of Medical Services | 77 |
| Number Of Medicare Beneficiaries With Medical Services | 28 |
| Total Medical Submitted Charge Amount | 12350 |
| Total Medical Medicare Allowed Amount | 6974.19 |
| Total Medical Medicare Payment Amount | 5404.42 |
| Total Medical Medicare Standardized Payment Amount | 5019.01 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 13 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | |
| Number Of Male Beneficiaries | |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 1.0489 |