| National Provider Identifier [NPI]: | 1285723957 |
| Last Name Of The Provider | HENNEBERRY |
| First Name Of The Provider | KYLE |
| 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 | 601 FRONT AVENUE |
| Street Address 2 Of The Provider | SUITE #502 |
| City Of The Provider | COEUR D ALENE |
| Zip Code Of The Provider | 83814 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 104 |
| Number Of Services | 1081 |
| Number Of Medicare Beneficiaries | 869 |
| Total Submitted Charge Amount | 115892 |
| Total Medicare Allowed Amount | 32840.09 |
| Total Medicare Payment Amount | 25423.92 |
| Total Medicare Standardized Payment Amount | 24577.36 |
| 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 | 104 |
| Number Of Medical Services | 1081 |
| Number Of Medicare Beneficiaries With Medical Services | 869 |
| Total Medical Submitted Charge Amount | 115892 |
| Total Medical Medicare Allowed Amount | 32840.09 |
| Total Medical Medicare Payment Amount | 25423.92 |
| Total Medical Medicare Standardized Payment Amount | 24577.36 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 209 |
| Number Of Beneficiaries Age 65 to 74 | 253 |
| Number Of Beneficiaries Age 75 to 84 | 230 |
| Number Of Beneficiaries Age Greater 84 | 177 |
| Number Of Female Beneficiaries | 476 |
| Number Of Male Beneficiaries | 393 |
| Number Of Non Hispanic White Beneficiaries | 567 |
| Number Of Black or African American Beneficiaries | 142 |
| Number Of AsianPacific Islander Beneficiaries | 31 |
| Number Of Hispanic Beneficiaries | 118 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 476 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 393 |
| Percent Of With Atrial Fibrillation | 21 |
| Percent Of With Alzheimers Disease or Dementia | 27 |
| Percent Of With Asthma | 16 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 45 |
| Percent Of With Chronic Kidney Disease | 49 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 33 |
| Percent Of With Depression | 39 |
| Percent Of With Diabetes | 49 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 55 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | 14 |
| Average HCC Risk Score Of Beneficiaries | 2.4517 |