| National Provider Identifier [NPI]: | 1376566760 |
| Last Name Of The Provider | CLUBB |
| First Name Of The Provider | SONI |
| Middle Initial Of The Provider | K |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | JOHN DEMPSEY HOSPITAL |
| Street Address 2 Of The Provider | 263 FARMINGTON AVENUE, MC-2801 |
| City Of The Provider | FARMINGTON |
| Zip Code Of The Provider | 060300001 |
| State Code Of The Provider | CT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 14 |
| Number Of Services | 218 |
| Number Of Medicare Beneficiaries | 200 |
| Total Submitted Charge Amount | 73639 |
| Total Medicare Allowed Amount | 25196.76 |
| Total Medicare Payment Amount | 19188.01 |
| Total Medicare Standardized Payment Amount | 18212.16 |
| 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 | 218 |
| Number Of Medicare Beneficiaries With Medical Services | 200 |
| Total Medical Submitted Charge Amount | 73639 |
| Total Medical Medicare Allowed Amount | 25196.76 |
| Total Medical Medicare Payment Amount | 19188.01 |
| Total Medical Medicare Standardized Payment Amount | 18212.16 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 50 |
| Number Of Beneficiaries Age 65 to 74 | 34 |
| Number Of Beneficiaries Age 75 to 84 | 49 |
| Number Of Beneficiaries Age Greater 84 | 67 |
| Number Of Female Beneficiaries | 114 |
| Number Of Male Beneficiaries | 86 |
| Number Of Non Hispanic White Beneficiaries | 165 |
| Number Of Black or African American Beneficiaries | 18 |
| 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 | 108 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 92 |
| Percent Of With Atrial Fibrillation | 21 |
| Percent Of With Alzheimers Disease or Dementia | 41 |
| Percent Of With Asthma | 15 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 37 |
| Percent Of With Chronic Kidney Disease | 39 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 30 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 48 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | 9 |
| Average HCC Risk Score Of Beneficiaries | 2.022 |