| National Provider Identifier [NPI]: | 1407859424 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | RICHARD |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | D.P.M. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 7601 W JEFFERSON BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468044133 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Podiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 34 |
| Number Of Services | 773 |
| Number Of Medicare Beneficiaries | 304 |
| Total Submitted Charge Amount | 87816 |
| Total Medicare Allowed Amount | 42617.94 |
| Total Medicare Payment Amount | 31004.11 |
| Total Medicare Standardized Payment Amount | 33739.55 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 46 |
| Number Of Medicare Beneficiaries With Drug Services | 27 |
| Total Drug Submitted ChargeAmount | 948 |
| Total Drug Medicare AllowedAmount | 185.85 |
| Total Drug Medicare PaymentAmount | 141.24 |
| Total Drug Medicare Standardized Payment Amount | 141.24 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 727 |
| Number Of Medicare Beneficiaries With Medical Services | 304 |
| Total Medical Submitted Charge Amount | 86868 |
| Total Medical Medicare Allowed Amount | 42432.09 |
| Total Medical Medicare Payment Amount | 30862.87 |
| Total Medical Medicare Standardized Payment Amount | 33598.31 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 63 |
| Number Of Beneficiaries Age 65 to 74 | 116 |
| Number Of Beneficiaries Age 75 to 84 | 82 |
| Number Of Beneficiaries Age Greater 84 | 43 |
| Number Of Female Beneficiaries | 194 |
| Number Of Male Beneficiaries | 110 |
| Number Of Non Hispanic White Beneficiaries | 281 |
| 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 | 239 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 65 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 49 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.3058 |