| National Provider Identifier [NPI]: | 1538480439 |
| Last Name Of The Provider | DERICKSON |
| First Name Of The Provider | KEITH |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | MD. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6404 ROTHMAN RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468351366 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 66 |
| Number Of Services | 1096 |
| Number Of Medicare Beneficiaries | 360 |
| Total Submitted Charge Amount | 153702 |
| Total Medicare Allowed Amount | 80873.33 |
| Total Medicare Payment Amount | 51981.85 |
| Total Medicare Standardized Payment Amount | 55315.33 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 14 |
| Number Of Drug Services | 88 |
| Number Of Medicare Beneficiaries With Drug Services | 47 |
| Total Drug Submitted ChargeAmount | 3551 |
| Total Drug Medicare AllowedAmount | 1494.67 |
| Total Drug Medicare PaymentAmount | 1425.74 |
| Total Drug Medicare Standardized Payment Amount | 1425.74 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 52 |
| Number Of Medical Services | 1008 |
| Number Of Medicare Beneficiaries With Medical Services | 360 |
| Total Medical Submitted Charge Amount | 150151 |
| Total Medical Medicare Allowed Amount | 79378.66 |
| Total Medical Medicare Payment Amount | 50556.11 |
| Total Medical Medicare Standardized Payment Amount | 53889.59 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 71 |
| Number Of Beneficiaries Age 65 to 74 | 171 |
| Number Of Beneficiaries Age 75 to 84 | 81 |
| Number Of Beneficiaries Age Greater 84 | 37 |
| Number Of Female Beneficiaries | 193 |
| Number Of Male Beneficiaries | 167 |
| Number Of Non Hispanic White Beneficiaries | 332 |
| Number Of Black or African American Beneficiaries | 12 |
| 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 | 298 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 62 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 24 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.069 |