| National Provider Identifier [NPI]: | 1669661450 |
| Last Name Of The Provider | SUPANWANID |
| First Name Of The Provider | PREECHA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 921 ABBOT RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | EAST LANSING |
| Zip Code Of The Provider | 488233170 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Plastic and Reconstructive Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 96 |
| Number Of Services | 763 |
| Number Of Medicare Beneficiaries | 280 |
| Total Submitted Charge Amount | 366000 |
| Total Medicare Allowed Amount | 208078.18 |
| Total Medicare Payment Amount | 160461.55 |
| Total Medicare Standardized Payment Amount | 162799.99 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 75 |
| Number Of Medicare Beneficiaries With Drug Services | 28 |
| Total Drug Submitted ChargeAmount | 1125 |
| Total Drug Medicare AllowedAmount | 133.02 |
| Total Drug Medicare PaymentAmount | 101.35 |
| Total Drug Medicare Standardized Payment Amount | 101.35 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 95 |
| Number Of Medical Services | 688 |
| Number Of Medicare Beneficiaries With Medical Services | 280 |
| Total Medical Submitted Charge Amount | 364875 |
| Total Medical Medicare Allowed Amount | 207945.16 |
| Total Medical Medicare Payment Amount | 160360.2 |
| Total Medical Medicare Standardized Payment Amount | 162698.64 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 30 |
| Number Of Beneficiaries Age 65 to 74 | 118 |
| Number Of Beneficiaries Age 75 to 84 | 91 |
| Number Of Beneficiaries Age Greater 84 | 41 |
| Number Of Female Beneficiaries | 127 |
| Number Of Male Beneficiaries | 153 |
| Number Of Non Hispanic White Beneficiaries | 249 |
| Number Of Black or African American Beneficiaries | 13 |
| 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 | 240 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 40 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0508 |