| National Provider Identifier [NPI]: | 1639264443 |
| Last Name Of The Provider | IDSTROM |
| First Name Of The Provider | MARK |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 9100 W 74TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | SHAWNEE MISSION |
| Zip Code Of The Provider | 662044004 |
| State Code Of The Provider | KS |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 78 |
| Number Of Services | 406 |
| Number Of Medicare Beneficiaries | 264 |
| Total Submitted Charge Amount | 142170 |
| Total Medicare Allowed Amount | 25853.94 |
| Total Medicare Payment Amount | 20250.99 |
| Total Medicare Standardized Payment Amount | 21126.37 |
| 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 | 78 |
| Number Of Medical Services | 406 |
| Number Of Medicare Beneficiaries With Medical Services | 264 |
| Total Medical Submitted Charge Amount | 142170 |
| Total Medical Medicare Allowed Amount | 25853.94 |
| Total Medical Medicare Payment Amount | 20250.99 |
| Total Medical Medicare Standardized Payment Amount | 21126.37 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 57 |
| Number Of Beneficiaries Age 65 to 74 | 89 |
| Number Of Beneficiaries Age 75 to 84 | 94 |
| Number Of Beneficiaries Age Greater 84 | 24 |
| Number Of Female Beneficiaries | 126 |
| Number Of Male Beneficiaries | 138 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 203 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 61 |
| Percent Of With Atrial Fibrillation | 23 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 18 |
| Percent Of With Heart Failure | 33 |
| Percent Of With Chronic Kidney Disease | 45 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 34 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 46 |
| Percent Of With Osteoporosis | 14 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 2.0072 |