| National Provider Identifier [NPI]: | 1184828030 |
| Last Name Of The Provider | JACKS |
| First Name Of The Provider | SAMUEL |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4622 COUNTRY CLUB RD |
| Street Address 2 Of The Provider | SUITE 180 |
| City Of The Provider | WINSTON SALEM |
| Zip Code Of The Provider | 271043769 |
| State Code Of The Provider | NC |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Cardiac Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 74 |
| Number Of Services | 468 |
| Number Of Medicare Beneficiaries | 264 |
| Total Submitted Charge Amount | 689191 |
| Total Medicare Allowed Amount | 233870.95 |
| Total Medicare Payment Amount | 181873.03 |
| Total Medicare Standardized Payment Amount | 175933.48 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 74 |
| Number Of Medical Services | 468 |
| Number Of Medicare Beneficiaries With Medical Services | 264 |
| Total Medical Submitted Charge Amount | 689191 |
| Total Medical Medicare Allowed Amount | 233870.95 |
| Total Medical Medicare Payment Amount | 181873.03 |
| Total Medical Medicare Standardized Payment Amount | 175933.48 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 50 |
| Number Of Beneficiaries Age 65 to 74 | 85 |
| Number Of Beneficiaries Age 75 to 84 | 79 |
| Number Of Beneficiaries Age Greater 84 | 50 |
| Number Of Female Beneficiaries | 122 |
| Number Of Male Beneficiaries | 142 |
| Number Of Non Hispanic White Beneficiaries | 200 |
| Number Of Black or African American Beneficiaries | 45 |
| 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 | 180 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 84 |
| Percent Of With Atrial Fibrillation | 32 |
| Percent Of With Alzheimers Disease or Dementia | 23 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 20 |
| Percent Of With Heart Failure | 66 |
| Percent Of With Chronic Kidney Disease | 65 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 56 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 59 |
| Percent Of With Hyperlipidemia | 75 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 75 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 10 |
| Percent Of With Stroke | 18 |
| Average HCC Risk Score Of Beneficiaries | 3.2715 |