| National Provider Identifier [NPI]: | 1902881287 |
| Last Name Of The Provider | WIDJAJA |
| First Name Of The Provider | JANI |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1000 MEDICAL CENTER BLVD |
| Street Address 2 Of The Provider | RADIOLOGY DEPT |
| City Of The Provider | LAWRENCEVILLE |
| Zip Code Of The Provider | 300457694 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 181 |
| Number Of Services | 4748 |
| Number Of Medicare Beneficiaries | 3218 |
| Total Submitted Charge Amount | 531916 |
| Total Medicare Allowed Amount | 138616.88 |
| Total Medicare Payment Amount | 103023.57 |
| Total Medicare Standardized Payment Amount | 103997.32 |
| 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 | 181 |
| Number Of Medical Services | 4748 |
| Number Of Medicare Beneficiaries With Medical Services | 3218 |
| Total Medical Submitted Charge Amount | 531916 |
| Total Medical Medicare Allowed Amount | 138616.88 |
| Total Medical Medicare Payment Amount | 103023.57 |
| Total Medical Medicare Standardized Payment Amount | 103997.32 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 492 |
| Number Of Beneficiaries Age 65 to 74 | 1232 |
| Number Of Beneficiaries Age 75 to 84 | 935 |
| Number Of Beneficiaries Age Greater 84 | 559 |
| Number Of Female Beneficiaries | 1990 |
| Number Of Male Beneficiaries | 1228 |
| Number Of Non Hispanic White Beneficiaries | 2342 |
| Number Of Black or African American Beneficiaries | 477 |
| Number Of AsianPacific Islander Beneficiaries | 183 |
| Number Of Hispanic Beneficiaries | 174 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 2440 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 778 |
| Percent Of With Atrial Fibrillation | 18 |
| Percent Of With Alzheimers Disease or Dementia | 20 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 16 |
| Percent Of With Heart Failure | 36 |
| Percent Of With Chronic Kidney Disease | 42 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 30 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 39 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 48 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | 11 |
| Average HCC Risk Score Of Beneficiaries | 1.8461 |