| National Provider Identifier [NPI]: | 1265623268 |
| Last Name Of The Provider | WAGNON |
| First Name Of The Provider | JON |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1368 DADRIAN PROFESSIONAL PARK |
| Street Address 2 Of The Provider | |
| City Of The Provider | GODFREY |
| Zip Code Of The Provider | 620351685 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 85 |
| Number Of Services | 2478 |
| Number Of Medicare Beneficiaries | 257 |
| Total Submitted Charge Amount | 420147.19 |
| Total Medicare Allowed Amount | 189570.12 |
| Total Medicare Payment Amount | 142693.33 |
| Total Medicare Standardized Payment Amount | 143782.56 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 96 |
| Number Of Medicare Beneficiaries With Drug Services | 41 |
| Total Drug Submitted ChargeAmount | 3055.72 |
| Total Drug Medicare AllowedAmount | 1085.76 |
| Total Drug Medicare PaymentAmount | 996.25 |
| Total Drug Medicare Standardized Payment Amount | 996.25 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 78 |
| Number Of Medical Services | 2382 |
| Number Of Medicare Beneficiaries With Medical Services | 257 |
| Total Medical Submitted Charge Amount | 417091.47 |
| Total Medical Medicare Allowed Amount | 188484.36 |
| Total Medical Medicare Payment Amount | 141697.08 |
| Total Medical Medicare Standardized Payment Amount | 142786.31 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 47 |
| Number Of Beneficiaries Age 65 to 74 | 80 |
| Number Of Beneficiaries Age 75 to 84 | 57 |
| Number Of Beneficiaries Age Greater 84 | 73 |
| Number Of Female Beneficiaries | 145 |
| Number Of Male Beneficiaries | 112 |
| Number Of Non Hispanic White Beneficiaries | 238 |
| 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 | 163 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 94 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 34 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 35 |
| Percent Of With Chronic Kidney Disease | 43 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 43 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 69 |
| Percent Of With Ischemic Heart Disease | 40 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.7415 |