| National Provider Identifier [NPI]: | 1780619890 |
| Last Name Of The Provider | SULLIVAN |
| First Name Of The Provider | KEVIN |
| 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 | 4700 POINT FOSDICK DR NW |
| Street Address 2 Of The Provider | STE 202 |
| City Of The Provider | GIG HARBOR |
| Zip Code Of The Provider | 983351706 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 151 |
| Number Of Medicare Beneficiaries | 43 |
| Total Submitted Charge Amount | 21558.01 |
| Total Medicare Allowed Amount | 9678.46 |
| Total Medicare Payment Amount | 5831.71 |
| Total Medicare Standardized Payment Amount | 6362.29 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 11 |
| Number Of Drug Services | 32 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 967.01 |
| Total Drug Medicare AllowedAmount | 551.37 |
| Total Drug Medicare PaymentAmount | 479.94 |
| Total Drug Medicare Standardized Payment Amount | 479.94 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 20 |
| Number Of Medical Services | 119 |
| Number Of Medicare Beneficiaries With Medical Services | 43 |
| Total Medical Submitted Charge Amount | 20591 |
| Total Medical Medicare Allowed Amount | 9127.09 |
| Total Medical Medicare Payment Amount | 5351.77 |
| Total Medical Medicare Standardized Payment Amount | 5882.35 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 15 |
| Number Of Male Beneficiaries | 28 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 0 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 40 |
| Percent Of With Hypertension | 40 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 1.5501 |