| National Provider Identifier [NPI]: | 1174607121 |
| Last Name Of The Provider | JUSTESEN |
| First Name Of The Provider | KENNETH |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4309 W MEDICAL CENTER DR |
| Street Address 2 Of The Provider | SUITE A201 |
| City Of The Provider | MCHENRY |
| Zip Code Of The Provider | 600508419 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Anesthesiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 65 |
| Number Of Services | 428 |
| Number Of Medicare Beneficiaries | 270 |
| Total Submitted Charge Amount | 104380.36 |
| Total Medicare Allowed Amount | 70016.25 |
| Total Medicare Payment Amount | 54892.59 |
| Total Medicare Standardized Payment Amount | 54943.84 |
| 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 | 65 |
| Number Of Medical Services | 428 |
| Number Of Medicare Beneficiaries With Medical Services | 270 |
| Total Medical Submitted Charge Amount | 104380.36 |
| Total Medical Medicare Allowed Amount | 70016.25 |
| Total Medical Medicare Payment Amount | 54892.59 |
| Total Medical Medicare Standardized Payment Amount | 54943.84 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 30 |
| Number Of Beneficiaries Age 65 to 74 | 138 |
| Number Of Beneficiaries Age 75 to 84 | 75 |
| Number Of Beneficiaries Age Greater 84 | 27 |
| Number Of Female Beneficiaries | 158 |
| Number Of Male Beneficiaries | 112 |
| 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 | 233 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 37 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 18 |
| Percent Of With Heart Failure | 32 |
| Percent Of With Chronic Kidney Disease | 29 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 28 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 51 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.3031 |