| National Provider Identifier [NPI]: | 1922061191 |
| Last Name Of The Provider | PETTIS |
| First Name Of The Provider | SAMUEL |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 742B BOYLSTON AVE E |
| Street Address 2 Of The Provider | |
| City Of The Provider | SEATTLE |
| Zip Code Of The Provider | 981024619 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nephrology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 14 |
| Number Of Services | 1169 |
| Number Of Medicare Beneficiaries | 238 |
| Total Submitted Charge Amount | 253657.17 |
| Total Medicare Allowed Amount | 95399.72 |
| Total Medicare Payment Amount | 74410.86 |
| Total Medicare Standardized Payment Amount | 75367.12 |
| 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 | 14 |
| Number Of Medical Services | 1169 |
| Number Of Medicare Beneficiaries With Medical Services | 238 |
| Total Medical Submitted Charge Amount | 253657.17 |
| Total Medical Medicare Allowed Amount | 95399.72 |
| Total Medical Medicare Payment Amount | 74410.86 |
| Total Medical Medicare Standardized Payment Amount | 75367.12 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 76 |
| Number Of Beneficiaries Age 65 to 74 | 71 |
| Number Of Beneficiaries Age 75 to 84 | 66 |
| Number Of Beneficiaries Age Greater 84 | 25 |
| Number Of Female Beneficiaries | 106 |
| Number Of Male Beneficiaries | 132 |
| Number Of Non Hispanic White Beneficiaries | 154 |
| Number Of Black or African American Beneficiaries | 38 |
| Number Of AsianPacific Islander Beneficiaries | 25 |
| 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 | 121 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 117 |
| Percent Of With Atrial Fibrillation | 27 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 73 |
| Percent Of With Chronic Kidney Disease | 75 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 36 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 68 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 61 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 15 |
| Average HCC Risk Score Of Beneficiaries | 5.0115 |