| National Provider Identifier [NPI]: | 1568440295 |
| Last Name Of The Provider | BANTA |
| First Name Of The Provider | LAWRENCE |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 211 E LOGAN ST |
| Street Address 2 Of The Provider | SUITE 201 |
| City Of The Provider | CALDWELL |
| Zip Code Of The Provider | 836054882 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Psychiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 21 |
| Number Of Services | 1395 |
| Number Of Medicare Beneficiaries | 279 |
| Total Submitted Charge Amount | 223554.15 |
| Total Medicare Allowed Amount | 109289.73 |
| Total Medicare Payment Amount | 80598.83 |
| Total Medicare Standardized Payment Amount | 85151.46 |
| Drug Suppress Indicator | * |
| Number Of HCPCS Associated With Drug Services | |
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| Number Of Medicare Beneficiaries With Drug Services | |
| Total Drug Submitted ChargeAmount | |
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| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
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| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
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| Average Age Of Beneficiaries | 60 |
| Number Of Beneficiaries Age Less65 | 160 |
| Number Of Beneficiaries Age 65 to 74 | 62 |
| Number Of Beneficiaries Age 75 to 84 | 38 |
| Number Of Beneficiaries Age Greater 84 | 19 |
| Number Of Female Beneficiaries | 163 |
| Number Of Male Beneficiaries | 116 |
| Number Of Non Hispanic White Beneficiaries | 244 |
| 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 | 56 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 223 |
| Percent Of With Atrial Fibrillation | 5 |
| Percent Of With Alzheimers Disease or Dementia | 44 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 5 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 75 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 34 |
| Percent Of With Hypertension | 55 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 57 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.6138 |