| National Provider Identifier [NPI]: | 1225122567 |
| Last Name Of The Provider | WALLIS |
| First Name Of The Provider | JEROLD |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 510 S KINGSHIGHWAY BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | SAINT LOUIS |
| Zip Code Of The Provider | 631101016 |
| State Code Of The Provider | MO |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 39 |
| Number Of Services | 981 |
| Number Of Medicare Beneficiaries | 921 |
| Total Submitted Charge Amount | 269930 |
| Total Medicare Allowed Amount | 55930.74 |
| Total Medicare Payment Amount | 43685.73 |
| Total Medicare Standardized Payment Amount | 44190.69 |
| 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 | 39 |
| Number Of Medical Services | 981 |
| Number Of Medicare Beneficiaries With Medical Services | 921 |
| Total Medical Submitted Charge Amount | 269930 |
| Total Medical Medicare Allowed Amount | 55930.74 |
| Total Medical Medicare Payment Amount | 43685.73 |
| Total Medical Medicare Standardized Payment Amount | 44190.69 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 209 |
| Number Of Beneficiaries Age 65 to 74 | 433 |
| Number Of Beneficiaries Age 75 to 84 | 217 |
| Number Of Beneficiaries Age Greater 84 | 62 |
| Number Of Female Beneficiaries | 553 |
| Number Of Male Beneficiaries | 368 |
| Number Of Non Hispanic White Beneficiaries | 735 |
| Number Of Black or African American Beneficiaries | 161 |
| Number Of AsianPacific Islander Beneficiaries | 11 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 727 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 194 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 5 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 31 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 33 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 45 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.8613 |