| National Provider Identifier [NPI]: | 1063446318 |
| Last Name Of The Provider | FOGO |
| First Name Of The Provider | SHANE |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 105 S MAJOR ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | EUREKA |
| Zip Code Of The Provider | 615301246 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 83 |
| Number Of Services | 1994 |
| Number Of Medicare Beneficiaries | 325 |
| Total Submitted Charge Amount | 272376.5 |
| Total Medicare Allowed Amount | 131921.1 |
| Total Medicare Payment Amount | 95894.71 |
| Total Medicare Standardized Payment Amount | 99100.29 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 19 |
| Number Of Drug Services | 362 |
| Number Of Medicare Beneficiaries With Drug Services | 111 |
| Total Drug Submitted ChargeAmount | 13875 |
| Total Drug Medicare AllowedAmount | 9486.02 |
| Total Drug Medicare PaymentAmount | 9251.8 |
| Total Drug Medicare Standardized Payment Amount | 9251.8 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 64 |
| Number Of Medical Services | 1632 |
| Number Of Medicare Beneficiaries With Medical Services | 325 |
| Total Medical Submitted Charge Amount | 258501.5 |
| Total Medical Medicare Allowed Amount | 122435.08 |
| Total Medical Medicare Payment Amount | 86642.91 |
| Total Medical Medicare Standardized Payment Amount | 89848.49 |
| Average Age Of Beneficiaries | 77 |
| Number Of Beneficiaries Age Less65 | 32 |
| Number Of Beneficiaries Age 65 to 74 | 107 |
| Number Of Beneficiaries Age 75 to 84 | 86 |
| Number Of Beneficiaries Age Greater 84 | 100 |
| Number Of Female Beneficiaries | 197 |
| Number Of Male Beneficiaries | 128 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 274 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 51 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 18 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 29 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.2112 |