| National Provider Identifier [NPI]: | 1780739284 |
| Last Name Of The Provider | PHETCHAMPHONE |
| First Name Of The Provider | SITSADAPHONE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | DC |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 504 LEGACY PLZ W |
| Street Address 2 Of The Provider | LA PORTE |
| City Of The Provider | LA PORTE |
| Zip Code Of The Provider | 463505254 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Chiropractic |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 2 |
| Number Of Services | 2559 |
| Number Of Medicare Beneficiaries | 229 |
| Total Submitted Charge Amount | 204090 |
| Total Medicare Allowed Amount | 100909.08 |
| Total Medicare Payment Amount | 77893.69 |
| Total Medicare Standardized Payment Amount | 82149.25 |
| 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 | 2 |
| Number Of Medical Services | 2559 |
| Number Of Medicare Beneficiaries With Medical Services | 229 |
| Total Medical Submitted Charge Amount | 204090 |
| Total Medical Medicare Allowed Amount | 100909.08 |
| Total Medical Medicare Payment Amount | 77893.69 |
| Total Medical Medicare Standardized Payment Amount | 82149.25 |
| Average Age Of Beneficiaries | 60 |
| Number Of Beneficiaries Age Less65 | 136 |
| Number Of Beneficiaries Age 65 to 74 | 62 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 122 |
| Number Of Male Beneficiaries | 107 |
| Number Of Non Hispanic White Beneficiaries | 175 |
| Number Of Black or African American Beneficiaries | 26 |
| 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 | 119 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 110 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 5 |
| Percent Of With Asthma | 17 |
| Percent Of With Cancer | 5 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 39 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.4131 |