| National Provider Identifier [NPI]: | 1568454304 |
| Last Name Of The Provider | WISIACKAS |
| First Name Of The Provider | PHILIP |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 110 HILL AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | COLDSPRING |
| Zip Code Of The Provider | 773315406 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 73 |
| Number Of Services | 2998 |
| Number Of Medicare Beneficiaries | 167 |
| Total Submitted Charge Amount | 247540 |
| Total Medicare Allowed Amount | 110213.67 |
| Total Medicare Payment Amount | 79257.6 |
| Total Medicare Standardized Payment Amount | 83541.46 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 58 |
| Number Of Medicare Beneficiaries With Drug Services | 51 |
| Total Drug Submitted ChargeAmount | 2655 |
| Total Drug Medicare AllowedAmount | 1394.7 |
| Total Drug Medicare PaymentAmount | 1361.68 |
| Total Drug Medicare Standardized Payment Amount | 1361.68 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 66 |
| Number Of Medical Services | 2940 |
| Number Of Medicare Beneficiaries With Medical Services | 167 |
| Total Medical Submitted Charge Amount | 244885 |
| Total Medical Medicare Allowed Amount | 108818.97 |
| Total Medical Medicare Payment Amount | 77895.92 |
| Total Medical Medicare Standardized Payment Amount | 82179.78 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 49 |
| Number Of Beneficiaries Age 65 to 74 | 68 |
| Number Of Beneficiaries Age 75 to 84 | 38 |
| Number Of Beneficiaries Age Greater 84 | 12 |
| Number Of Female Beneficiaries | 91 |
| Number Of Male Beneficiaries | 76 |
| Number Of Non Hispanic White Beneficiaries | 133 |
| 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 | 91 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 76 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 21 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 30 |
| Percent Of With Chronic Kidney Disease | 32 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 29 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 37 |
| Percent Of With Hyperlipidemia | 69 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.5712 |