| National Provider Identifier [NPI]: | 1275631020 |
| Last Name Of The Provider | FULLEN |
| First Name Of The Provider | JERYL |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1101 MICHIGAN AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | LOGANSPORT |
| Zip Code Of The Provider | 469471528 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Orthopedic Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 58 |
| Number Of Services | 553 |
| Number Of Medicare Beneficiaries | 183 |
| Total Submitted Charge Amount | 108309 |
| Total Medicare Allowed Amount | 66910.46 |
| Total Medicare Payment Amount | 50485.68 |
| Total Medicare Standardized Payment Amount | 54081.92 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 160 |
| Number Of Medicare Beneficiaries With Drug Services | 30 |
| Total Drug Submitted ChargeAmount | 3483 |
| Total Drug Medicare AllowedAmount | 1798.65 |
| Total Drug Medicare PaymentAmount | 1324.17 |
| Total Drug Medicare Standardized Payment Amount | 1324.17 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 54 |
| Number Of Medical Services | 393 |
| Number Of Medicare Beneficiaries With Medical Services | 183 |
| Total Medical Submitted Charge Amount | 104826 |
| Total Medical Medicare Allowed Amount | 65111.81 |
| Total Medical Medicare Payment Amount | 49161.51 |
| Total Medical Medicare Standardized Payment Amount | 52757.75 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 50 |
| Number Of Beneficiaries Age 65 to 74 | 52 |
| Number Of Beneficiaries Age 75 to 84 | 44 |
| Number Of Beneficiaries Age Greater 84 | 37 |
| Number Of Female Beneficiaries | 123 |
| Number Of Male Beneficiaries | 60 |
| 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 | 120 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 63 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 25 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 17 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 67 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 11 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.3413 |