| National Provider Identifier [NPI]: | 1093703811 |
| Last Name Of The Provider | WOLTHUIS |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4700 HARRISON BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | OGDEN |
| Zip Code Of The Provider | 844034303 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Urology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 56 |
| Number Of Services | 434 |
| Number Of Medicare Beneficiaries | 146 |
| Total Submitted Charge Amount | 76848 |
| Total Medicare Allowed Amount | 33057.85 |
| Total Medicare Payment Amount | 23455.63 |
| Total Medicare Standardized Payment Amount | 24411.44 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 82 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 18424 |
| Total Drug Medicare AllowedAmount | 8512.4 |
| Total Drug Medicare PaymentAmount | 6409.67 |
| Total Drug Medicare Standardized Payment Amount | 6409.67 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 53 |
| Number Of Medical Services | 352 |
| Number Of Medicare Beneficiaries With Medical Services | 146 |
| Total Medical Submitted Charge Amount | 58424 |
| Total Medical Medicare Allowed Amount | 24545.45 |
| Total Medical Medicare Payment Amount | 17045.96 |
| Total Medical Medicare Standardized Payment Amount | 18001.77 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 11 |
| Number Of Beneficiaries Age 65 to 74 | 51 |
| Number Of Beneficiaries Age 75 to 84 | 50 |
| Number Of Beneficiaries Age Greater 84 | 34 |
| Number Of Female Beneficiaries | 27 |
| Number Of Male Beneficiaries | 119 |
| Number Of Non Hispanic White Beneficiaries | 126 |
| 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 | 133 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 13 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 27 |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 9 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 42 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0947 |