| National Provider Identifier [NPI]: | 1609850130 |
| Last Name Of The Provider | TOM |
| First Name Of The Provider | KEITH |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 49221 VAN DYKE |
| Street Address 2 Of The Provider | |
| City Of The Provider | SHELBY TWP |
| Zip Code Of The Provider | 483171336 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 55 |
| Number Of Services | 1723 |
| Number Of Medicare Beneficiaries | 165 |
| Total Submitted Charge Amount | 112575 |
| Total Medicare Allowed Amount | 87435.73 |
| Total Medicare Payment Amount | 61242.95 |
| Total Medicare Standardized Payment Amount | 61154.4 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 65 |
| Number Of Medicare Beneficiaries With Drug Services | 57 |
| Total Drug Submitted ChargeAmount | 1510 |
| Total Drug Medicare AllowedAmount | 608.52 |
| Total Drug Medicare PaymentAmount | 545.94 |
| Total Drug Medicare Standardized Payment Amount | 545.94 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 51 |
| Number Of Medical Services | 1658 |
| Number Of Medicare Beneficiaries With Medical Services | 165 |
| Total Medical Submitted Charge Amount | 111065 |
| Total Medical Medicare Allowed Amount | 86827.21 |
| Total Medical Medicare Payment Amount | 60697.01 |
| Total Medical Medicare Standardized Payment Amount | 60608.46 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 24 |
| Number Of Beneficiaries Age 65 to 74 | 81 |
| Number Of Beneficiaries Age 75 to 84 | 44 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 72 |
| Number Of Male Beneficiaries | 93 |
| 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 | 143 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 22 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 22 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9872 |