| National Provider Identifier [NPI]: | 1639199862 |
| Last Name Of The Provider | TIDWELL |
| First Name Of The Provider | JUSTIN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 604 INDIANA |
| Street Address 2 Of The Provider | |
| City Of The Provider | LUBBOCK |
| Zip Code Of The Provider | 79415 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 17 |
| Number Of Services | 564 |
| Number Of Medicare Beneficiaries | 524 |
| Total Submitted Charge Amount | 262397 |
| Total Medicare Allowed Amount | 75440.75 |
| Total Medicare Payment Amount | 54592.35 |
| Total Medicare Standardized Payment Amount | 56484.81 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 17 |
| Number Of Medical Services | 564 |
| Number Of Medicare Beneficiaries With Medical Services | 524 |
| Total Medical Submitted Charge Amount | 262397 |
| Total Medical Medicare Allowed Amount | 75440.75 |
| Total Medical Medicare Payment Amount | 54592.35 |
| Total Medical Medicare Standardized Payment Amount | 56484.81 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 156 |
| Number Of Beneficiaries Age 65 to 74 | 147 |
| Number Of Beneficiaries Age 75 to 84 | 141 |
| Number Of Beneficiaries Age Greater 84 | 80 |
| Number Of Female Beneficiaries | 274 |
| Number Of Male Beneficiaries | 250 |
| Number Of Non Hispanic White Beneficiaries | 319 |
| Number Of Black or African American Beneficiaries | 55 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 139 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 304 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 220 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 24 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 47 |
| Percent Of With Chronic Kidney Disease | 47 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 27 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 45 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 62 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | 13 |
| Average HCC Risk Score Of Beneficiaries | 2.2735 |