| National Provider Identifier [NPI]: | 1710908892 |
| Last Name Of The Provider | TIDWELL |
| First Name Of The Provider | JUSTIN |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | DPM |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 501 N GRAHAM ST |
| Street Address 2 Of The Provider | SUITE 415 |
| City Of The Provider | PORTLAND |
| Zip Code Of The Provider | 972271654 |
| State Code Of The Provider | OR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Podiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 62 |
| Number Of Services | 986 |
| Number Of Medicare Beneficiaries | 253 |
| Total Submitted Charge Amount | 267634.2 |
| Total Medicare Allowed Amount | 80852.78 |
| Total Medicare Payment Amount | 58637.25 |
| Total Medicare Standardized Payment Amount | 59502.21 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 41 |
| Number Of Medicare Beneficiaries With Drug Services | 18 |
| Total Drug Submitted ChargeAmount | 196.2 |
| Total Drug Medicare AllowedAmount | 70.39 |
| Total Drug Medicare PaymentAmount | 51.2 |
| Total Drug Medicare Standardized Payment Amount | 51.2 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 59 |
| Number Of Medical Services | 945 |
| Number Of Medicare Beneficiaries With Medical Services | 253 |
| Total Medical Submitted Charge Amount | 267438 |
| Total Medical Medicare Allowed Amount | 80782.39 |
| Total Medical Medicare Payment Amount | 58586.05 |
| Total Medical Medicare Standardized Payment Amount | 59451.01 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 59 |
| Number Of Beneficiaries Age 65 to 74 | 110 |
| Number Of Beneficiaries Age 75 to 84 | 53 |
| Number Of Beneficiaries Age Greater 84 | 31 |
| Number Of Female Beneficiaries | 146 |
| Number Of Male Beneficiaries | 107 |
| Number Of Non Hispanic White Beneficiaries | 213 |
| Number Of Black or African American Beneficiaries | 26 |
| 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 | 182 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 71 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 24 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 9 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 51 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.7573 |