| National Provider Identifier [NPI]: | 1992949721 |
| Last Name Of The Provider | GUSTAFSON |
| First Name Of The Provider | KIMARA |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | M.D., M.P.H |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 420 DELAWARE ST SE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MINNEAPOLIS |
| Zip Code Of The Provider | 554550341 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pediatric Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 27 |
| Number Of Services | 256 |
| Number Of Medicare Beneficiaries | 85 |
| Total Submitted Charge Amount | 7285.24 |
| Total Medicare Allowed Amount | 4254.62 |
| Total Medicare Payment Amount | 3770.17 |
| Total Medicare Standardized Payment Amount | 3620.25 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 103 |
| Number Of Medicare Beneficiaries With Drug Services | 39 |
| Total Drug Submitted ChargeAmount | 2574.62 |
| Total Drug Medicare AllowedAmount | 1595.42 |
| Total Drug Medicare PaymentAmount | 1386.81 |
| Total Drug Medicare Standardized Payment Amount | 1386.81 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 153 |
| Number Of Medicare Beneficiaries With Medical Services | 85 |
| Total Medical Submitted Charge Amount | 4710.62 |
| Total Medical Medicare Allowed Amount | 2659.2 |
| Total Medical Medicare Payment Amount | 2383.36 |
| Total Medical Medicare Standardized Payment Amount | 2233.44 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 26 |
| Number Of Beneficiaries Age 65 to 74 | 22 |
| Number Of Beneficiaries Age 75 to 84 | 19 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 48 |
| Number Of Male Beneficiaries | 37 |
| 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 | 60 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 25 |
| Percent Of With Atrial Fibrillation | 25 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 35 |
| Percent Of With Hypertension | 51 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 1.1289 |