| National Provider Identifier [NPI]: | 1942315577 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3909 NEW VISION DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468451725 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 32 |
| Number Of Services | 1029 |
| Number Of Medicare Beneficiaries | 257 |
| Total Submitted Charge Amount | 119013 |
| Total Medicare Allowed Amount | 65230.96 |
| Total Medicare Payment Amount | 44062.98 |
| Total Medicare Standardized Payment Amount | 47311.75 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 135 |
| Number Of Medicare Beneficiaries With Drug Services | 101 |
| Total Drug Submitted ChargeAmount | 14276 |
| Total Drug Medicare AllowedAmount | 6045.65 |
| Total Drug Medicare PaymentAmount | 5901.93 |
| Total Drug Medicare Standardized Payment Amount | 5901.93 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 25 |
| Number Of Medical Services | 894 |
| Number Of Medicare Beneficiaries With Medical Services | 257 |
| Total Medical Submitted Charge Amount | 104737 |
| Total Medical Medicare Allowed Amount | 59185.31 |
| Total Medical Medicare Payment Amount | 38161.05 |
| Total Medical Medicare Standardized Payment Amount | 41409.82 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 22 |
| Number Of Beneficiaries Age 65 to 74 | 111 |
| Number Of Beneficiaries Age 75 to 84 | 69 |
| Number Of Beneficiaries Age Greater 84 | 55 |
| Number Of Female Beneficiaries | 148 |
| Number Of Male Beneficiaries | 109 |
| 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 | 237 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 20 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 11 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9475 |