| National Provider Identifier [NPI]: | 1538100128 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | LANCE |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 20939 S CICERO AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MATTESON |
| Zip Code Of The Provider | 604431620 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 46 |
| Number Of Services | 1737 |
| Number Of Medicare Beneficiaries | 379 |
| Total Submitted Charge Amount | 173384.3 |
| Total Medicare Allowed Amount | 171317.2 |
| Total Medicare Payment Amount | 120575.68 |
| Total Medicare Standardized Payment Amount | 115060.96 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 151 |
| Number Of Medicare Beneficiaries With Drug Services | 99 |
| Total Drug Submitted ChargeAmount | 3117.44 |
| Total Drug Medicare AllowedAmount | 3050.58 |
| Total Drug Medicare PaymentAmount | 2923.44 |
| Total Drug Medicare Standardized Payment Amount | 2923.44 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 40 |
| Number Of Medical Services | 1586 |
| Number Of Medicare Beneficiaries With Medical Services | 379 |
| Total Medical Submitted Charge Amount | 170266.86 |
| Total Medical Medicare Allowed Amount | 168266.62 |
| Total Medical Medicare Payment Amount | 117652.24 |
| Total Medical Medicare Standardized Payment Amount | 112137.52 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 46 |
| Number Of Beneficiaries Age 65 to 74 | 182 |
| Number Of Beneficiaries Age 75 to 84 | 114 |
| Number Of Beneficiaries Age Greater 84 | 37 |
| Number Of Female Beneficiaries | 224 |
| Number Of Male Beneficiaries | 155 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | 301 |
| 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 | 269 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 110 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 22 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 24 |
| Percent Of With Chronic Kidney Disease | 32 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 49 |
| Percent Of With Hyperlipidemia | 68 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 57 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.5245 |