| National Provider Identifier [NPI]: | 1043293921 |
| Last Name Of The Provider | GILLESPIE-WAGNER |
| First Name Of The Provider | JAN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1175 58TH AVE |
| Street Address 2 Of The Provider | STE 200 |
| City Of The Provider | GREELEY |
| Zip Code Of The Provider | 806344807 |
| State Code Of The Provider | CO |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Interventional Pain Management |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 2815 |
| Number Of Medicare Beneficiaries | 154 |
| Total Submitted Charge Amount | 311733 |
| Total Medicare Allowed Amount | 154398.42 |
| Total Medicare Payment Amount | 112064.92 |
| Total Medicare Standardized Payment Amount | 111391.96 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 13 |
| Number Of Drug Services | 1315 |
| Number Of Medicare Beneficiaries With Drug Services | 67 |
| Total Drug Submitted ChargeAmount | 8979 |
| Total Drug Medicare AllowedAmount | 2293.43 |
| Total Drug Medicare PaymentAmount | 1763.96 |
| Total Drug Medicare Standardized Payment Amount | 1763.96 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 32 |
| Number Of Medical Services | 1500 |
| Number Of Medicare Beneficiaries With Medical Services | 154 |
| Total Medical Submitted Charge Amount | 302754 |
| Total Medical Medicare Allowed Amount | 152104.99 |
| Total Medical Medicare Payment Amount | 110300.96 |
| Total Medical Medicare Standardized Payment Amount | 109628 |
| Average Age Of Beneficiaries | 57 |
| Number Of Beneficiaries Age Less65 | 111 |
| Number Of Beneficiaries Age 65 to 74 | 24 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 101 |
| Number Of Male Beneficiaries | 53 |
| Number Of Non Hispanic White Beneficiaries | 118 |
| 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 | 77 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 77 |
| Percent Of With Atrial Fibrillation | 0 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 8 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 45 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 25 |
| Percent Of With Hypertension | 46 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 69 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.3111 |