| National Provider Identifier [NPI]: | 1134108756 |
| Last Name Of The Provider | GUSTAFSON |
| 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 | 1802 BRAEBURN DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | SALEM |
| Zip Code Of The Provider | 241537357 |
| State Code Of The Provider | VA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Obstetrics/Gynecology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 74 |
| Number Of Services | 1119 |
| Number Of Medicare Beneficiaries | 415 |
| Total Submitted Charge Amount | 209125 |
| Total Medicare Allowed Amount | 69432.99 |
| Total Medicare Payment Amount | 51959 |
| Total Medicare Standardized Payment Amount | 53315.23 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 71 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 3103 |
| Total Drug Medicare AllowedAmount | 999.37 |
| Total Drug Medicare PaymentAmount | 712.6 |
| Total Drug Medicare Standardized Payment Amount | 712.6 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 71 |
| Number Of Medical Services | 1048 |
| Number Of Medicare Beneficiaries With Medical Services | 415 |
| Total Medical Submitted Charge Amount | 206022 |
| Total Medical Medicare Allowed Amount | 68433.62 |
| Total Medical Medicare Payment Amount | 51246.4 |
| Total Medical Medicare Standardized Payment Amount | 52602.63 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 64 |
| Number Of Beneficiaries Age 65 to 74 | 189 |
| Number Of Beneficiaries Age 75 to 84 | 127 |
| Number Of Beneficiaries Age Greater 84 | 35 |
| Number Of Female Beneficiaries | 415 |
| Number Of Male Beneficiaries | 0 |
| Number Of Non Hispanic White Beneficiaries | 363 |
| Number Of Black or African American Beneficiaries | 41 |
| 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 | 361 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 54 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 6 |
| Percent Of With Chronic Kidney Disease | 8 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 5 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 58 |
| Percent Of With Ischemic Heart Disease | 17 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 0.8568 |