| National Provider Identifier [NPI]: | 1245319599 |
| Last Name Of The Provider | SAMPLE |
| First Name Of The Provider | LAURA |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1080 FIRST COLONIAL RD |
| Street Address 2 Of The Provider | SUITE 200 |
| City Of The Provider | VIRGINIA BEACH |
| Zip Code Of The Provider | 234542406 |
| State Code Of The Provider | VA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 26 |
| Number Of Services | 1091 |
| Number Of Medicare Beneficiaries | 336 |
| Total Submitted Charge Amount | 164028 |
| Total Medicare Allowed Amount | 81523.59 |
| Total Medicare Payment Amount | 55114.77 |
| Total Medicare Standardized Payment Amount | 57469.96 |
| 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 | 26 |
| Number Of Medical Services | 1091 |
| Number Of Medicare Beneficiaries With Medical Services | 336 |
| Total Medical Submitted Charge Amount | 164028 |
| Total Medical Medicare Allowed Amount | 81523.59 |
| Total Medical Medicare Payment Amount | 55114.77 |
| Total Medical Medicare Standardized Payment Amount | 57469.96 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 60 |
| Number Of Beneficiaries Age 65 to 74 | 171 |
| Number Of Beneficiaries Age 75 to 84 | 76 |
| Number Of Beneficiaries Age Greater 84 | 29 |
| Number Of Female Beneficiaries | 244 |
| Number Of Male Beneficiaries | 92 |
| Number Of Non Hispanic White Beneficiaries | 290 |
| Number Of Black or African American Beneficiaries | 28 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 282 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 54 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 64 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.1225 |