| National Provider Identifier [NPI]: | 1831486596 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | JOHN |
| 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 | 332 HIGHWAY 12 W |
| Street Address 2 Of The Provider | |
| City Of The Provider | KOSCIUSKO |
| Zip Code Of The Provider | 390903209 |
| State Code Of The Provider | MS |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 139 |
| Number Of Services | 2875 |
| Number Of Medicare Beneficiaries | 303 |
| Total Submitted Charge Amount | 114796 |
| Total Medicare Allowed Amount | 64942.02 |
| Total Medicare Payment Amount | 51349.68 |
| Total Medicare Standardized Payment Amount | 55877.65 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 18 |
| Number Of Drug Services | 1434 |
| Number Of Medicare Beneficiaries With Drug Services | 92 |
| Total Drug Submitted ChargeAmount | 6831 |
| Total Drug Medicare AllowedAmount | 2575.89 |
| Total Drug Medicare PaymentAmount | 2332.69 |
| Total Drug Medicare Standardized Payment Amount | 2332.69 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 121 |
| Number Of Medical Services | 1441 |
| Number Of Medicare Beneficiaries With Medical Services | 302 |
| Total Medical Submitted Charge Amount | 107965 |
| Total Medical Medicare Allowed Amount | 62366.13 |
| Total Medical Medicare Payment Amount | 49016.99 |
| Total Medical Medicare Standardized Payment Amount | 53544.96 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 69 |
| Number Of Beneficiaries Age 65 to 74 | 100 |
| Number Of Beneficiaries Age 75 to 84 | 94 |
| Number Of Beneficiaries Age Greater 84 | 40 |
| Number Of Female Beneficiaries | 197 |
| Number Of Male Beneficiaries | 106 |
| Number Of Non Hispanic White Beneficiaries | 230 |
| 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 | 200 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 103 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 17 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 22 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 21 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 43 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.2023 |