| National Provider Identifier [NPI]: | 1063454122 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1055 N CURTIS RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | BOISE |
| Zip Code Of The Provider | 837061309 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 208 |
| Number Of Services | 7501 |
| Number Of Medicare Beneficiaries | 1568 |
| Total Submitted Charge Amount | 312398.67 |
| Total Medicare Allowed Amount | 142677.02 |
| Total Medicare Payment Amount | 105523.43 |
| Total Medicare Standardized Payment Amount | 115862.55 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 5297 |
| Number Of Medicare Beneficiaries With Drug Services | 123 |
| Total Drug Submitted ChargeAmount | 3324.26 |
| Total Drug Medicare AllowedAmount | 2860.61 |
| Total Drug Medicare PaymentAmount | 2214.13 |
| Total Drug Medicare Standardized Payment Amount | 2214.13 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 198 |
| Number Of Medical Services | 2204 |
| Number Of Medicare Beneficiaries With Medical Services | 1567 |
| Total Medical Submitted Charge Amount | 309074.41 |
| Total Medical Medicare Allowed Amount | 139816.41 |
| Total Medical Medicare Payment Amount | 103309.3 |
| Total Medical Medicare Standardized Payment Amount | 113648.42 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 377 |
| Number Of Beneficiaries Age 65 to 74 | 529 |
| Number Of Beneficiaries Age 75 to 84 | 430 |
| Number Of Beneficiaries Age Greater 84 | 232 |
| Number Of Female Beneficiaries | 872 |
| Number Of Male Beneficiaries | 696 |
| Number Of Non Hispanic White Beneficiaries | 1421 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 18 |
| Number Of Hispanic Beneficiaries | 96 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 14 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1068 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 500 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 30 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 26 |
| Percent Of With Depression | 39 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 37 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 53 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.5928 |