| National Provider Identifier [NPI]: | 1497878474 |
| Last Name Of The Provider | FORMES |
| First Name Of The Provider | KEVIN |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1002 TEXAS BLVD |
| Street Address 2 Of The Provider | SUITE 401 |
| City Of The Provider | TEXARKANA |
| Zip Code Of The Provider | 755015107 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Cardiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 55 |
| Number Of Services | 4267 |
| Number Of Medicare Beneficiaries | 1359 |
| Total Submitted Charge Amount | 662401 |
| Total Medicare Allowed Amount | 334214.5 |
| Total Medicare Payment Amount | 248766.9 |
| Total Medicare Standardized Payment Amount | 254078.45 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 224 |
| Number Of Medicare Beneficiaries With Drug Services | 56 |
| Total Drug Submitted ChargeAmount | 20160 |
| Total Drug Medicare AllowedAmount | 11870.77 |
| Total Drug Medicare PaymentAmount | 9306.63 |
| Total Drug Medicare Standardized Payment Amount | 9306.63 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 54 |
| Number Of Medical Services | 4043 |
| Number Of Medicare Beneficiaries With Medical Services | 1359 |
| Total Medical Submitted Charge Amount | 642241 |
| Total Medical Medicare Allowed Amount | 322343.73 |
| Total Medical Medicare Payment Amount | 239460.27 |
| Total Medical Medicare Standardized Payment Amount | 244771.82 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 250 |
| Number Of Beneficiaries Age 65 to 74 | 542 |
| Number Of Beneficiaries Age 75 to 84 | 392 |
| Number Of Beneficiaries Age Greater 84 | 175 |
| Number Of Female Beneficiaries | 702 |
| Number Of Male Beneficiaries | 657 |
| Number Of Non Hispanic White Beneficiaries | 1084 |
| Number Of Black or African American Beneficiaries | 240 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 16 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 945 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 414 |
| Percent Of With Atrial Fibrillation | 28 |
| Percent Of With Alzheimers Disease or Dementia | 18 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 60 |
| Percent Of With Chronic Kidney Disease | 29 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 32 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 72 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 15 |
| Average HCC Risk Score Of Beneficiaries | 1.5427 |