| National Provider Identifier [NPI]: | 1821082124 |
| Last Name Of The Provider | FORMBY |
| First Name Of The Provider | LARRY |
| Middle Initial Of The Provider | H |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1013 N 5TH AVE NE |
| Street Address 2 Of The Provider | STE ONE |
| City Of The Provider | ROME |
| Zip Code Of The Provider | 301652664 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Urology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 61 |
| Number Of Services | 5538 |
| Number Of Medicare Beneficiaries | 587 |
| Total Submitted Charge Amount | 565628 |
| Total Medicare Allowed Amount | 201419.71 |
| Total Medicare Payment Amount | 146479.38 |
| Total Medicare Standardized Payment Amount | 156273.68 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 1792 |
| Number Of Medicare Beneficiaries With Drug Services | 76 |
| Total Drug Submitted ChargeAmount | 128207 |
| Total Drug Medicare AllowedAmount | 36928.48 |
| Total Drug Medicare PaymentAmount | 28421.03 |
| Total Drug Medicare Standardized Payment Amount | 28421.03 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 53 |
| Number Of Medical Services | 3746 |
| Number Of Medicare Beneficiaries With Medical Services | 587 |
| Total Medical Submitted Charge Amount | 437421 |
| Total Medical Medicare Allowed Amount | 164491.23 |
| Total Medical Medicare Payment Amount | 118058.35 |
| Total Medical Medicare Standardized Payment Amount | 127852.65 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 55 |
| Number Of Beneficiaries Age 65 to 74 | 244 |
| Number Of Beneficiaries Age 75 to 84 | 228 |
| Number Of Beneficiaries Age Greater 84 | 60 |
| Number Of Female Beneficiaries | 153 |
| Number Of Male Beneficiaries | 434 |
| Number Of Non Hispanic White Beneficiaries | 552 |
| 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 | 515 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 72 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 4 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.1058 |