| National Provider Identifier [NPI]: | 1629273941 |
| Last Name Of The Provider | KOTLYAR |
| First Name Of The Provider | SIMON |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1010 THREE SPRINGS BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | DURANGO |
| Zip Code Of The Provider | 813018296 |
| State Code Of The Provider | CO |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 109 |
| Number Of Services | 657 |
| Number Of Medicare Beneficiaries | 128 |
| Total Submitted Charge Amount | 107394 |
| Total Medicare Allowed Amount | 26142.82 |
| Total Medicare Payment Amount | 19117.33 |
| Total Medicare Standardized Payment Amount | 18954.43 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 19 |
| Number Of Drug Services | 155 |
| Number Of Medicare Beneficiaries With Drug Services | 24 |
| Total Drug Submitted ChargeAmount | 2409 |
| Total Drug Medicare AllowedAmount | 168.36 |
| Total Drug Medicare PaymentAmount | 119.5 |
| Total Drug Medicare Standardized Payment Amount | 119.5 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 90 |
| Number Of Medical Services | 502 |
| Number Of Medicare Beneficiaries With Medical Services | 128 |
| Total Medical Submitted Charge Amount | 104985 |
| Total Medical Medicare Allowed Amount | 25974.46 |
| Total Medical Medicare Payment Amount | 18997.83 |
| Total Medical Medicare Standardized Payment Amount | 18834.93 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 69 |
| Number Of Beneficiaries Age 75 to 84 | 31 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 56 |
| Number Of Male Beneficiaries | 72 |
| Number Of Non Hispanic White Beneficiaries | 112 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 106 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 22 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 30 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 53 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2182 |