| National Provider Identifier [NPI]: | 1275582884 |
| Last Name Of The Provider | HAITHCOCK |
| First Name Of The Provider | KELLY |
| Middle Initial Of The Provider | K |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6551 HARRIS PKWY |
| Street Address 2 Of The Provider | SUITE 200 |
| City Of The Provider | FT WORTH |
| Zip Code Of The Provider | 761326103 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Ophthalmology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 23 |
| Number Of Services | 1975 |
| Number Of Medicare Beneficiaries | 1162 |
| Total Submitted Charge Amount | 615250 |
| Total Medicare Allowed Amount | 264006.15 |
| Total Medicare Payment Amount | 181873.12 |
| Total Medicare Standardized Payment Amount | 187304.08 |
| 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 | 23 |
| Number Of Medical Services | 1975 |
| Number Of Medicare Beneficiaries With Medical Services | 1162 |
| Total Medical Submitted Charge Amount | 615250 |
| Total Medical Medicare Allowed Amount | 264006.15 |
| Total Medical Medicare Payment Amount | 181873.12 |
| Total Medical Medicare Standardized Payment Amount | 187304.08 |
| Average Age Of Beneficiaries | 78 |
| Number Of Beneficiaries Age Less65 | 15 |
| Number Of Beneficiaries Age 65 to 74 | 392 |
| Number Of Beneficiaries Age 75 to 84 | 546 |
| Number Of Beneficiaries Age Greater 84 | 209 |
| Number Of Female Beneficiaries | 699 |
| Number Of Male Beneficiaries | 463 |
| Number Of Non Hispanic White Beneficiaries | 1074 |
| Number Of Black or African American Beneficiaries | 42 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 31 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 1151 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 11 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 69 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 1 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.0279 |