| National Provider Identifier [NPI]: | 1265463996 |
| Last Name Of The Provider | FELLIN |
| First Name Of The Provider | SAMUEL |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 12442 SW SCHOLLS FERRY RD |
| Street Address 2 Of The Provider | SUITE 106 |
| City Of The Provider | TIGARD |
| Zip Code Of The Provider | 972233396 |
| State Code Of The Provider | OR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 37 |
| Number Of Services | 542 |
| Number Of Medicare Beneficiaries | 192 |
| Total Submitted Charge Amount | 139544.5 |
| Total Medicare Allowed Amount | 45258.9 |
| Total Medicare Payment Amount | 30185.62 |
| Total Medicare Standardized Payment Amount | 29939.68 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 32 |
| Number Of Medicare Beneficiaries With Drug Services | 24 |
| Total Drug Submitted ChargeAmount | 975 |
| Total Drug Medicare AllowedAmount | 563.1 |
| Total Drug Medicare PaymentAmount | 548.36 |
| Total Drug Medicare Standardized Payment Amount | 548.36 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 30 |
| Number Of Medical Services | 510 |
| Number Of Medicare Beneficiaries With Medical Services | 192 |
| Total Medical Submitted Charge Amount | 138569.5 |
| Total Medical Medicare Allowed Amount | 44695.8 |
| Total Medical Medicare Payment Amount | 29637.26 |
| Total Medical Medicare Standardized Payment Amount | 29391.32 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 32 |
| Number Of Beneficiaries Age 65 to 74 | 60 |
| Number Of Beneficiaries Age 75 to 84 | 58 |
| Number Of Beneficiaries Age Greater 84 | 42 |
| Number Of Female Beneficiaries | 85 |
| Number Of Male Beneficiaries | 107 |
| Number Of Non Hispanic White Beneficiaries | 172 |
| Number Of Black or African American Beneficiaries | |
| 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 | 159 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 33 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 22 |
| Percent Of With Hyperlipidemia | 36 |
| Percent Of With Hypertension | 53 |
| Percent Of With Ischemic Heart Disease | 19 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.042 |