| National Provider Identifier [NPI]: | 1326161266 |
| Last Name Of The Provider | SAMPLE |
| First Name Of The Provider | STEPHEN |
| 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 | 48 MDG/SGOE UNIT 5210 BOX 230 |
| Street Address 2 Of The Provider | |
| City Of The Provider | APO |
| Zip Code Of The Provider | 094610230 |
| State Code Of The Provider | AE |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 41 |
| Number Of Services | 847 |
| Number Of Medicare Beneficiaries | 697 |
| Total Submitted Charge Amount | 542764 |
| Total Medicare Allowed Amount | 107895.9 |
| Total Medicare Payment Amount | 77436.03 |
| Total Medicare Standardized Payment Amount | 80527.21 |
| 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 | 41 |
| Number Of Medical Services | 847 |
| Number Of Medicare Beneficiaries With Medical Services | 697 |
| Total Medical Submitted Charge Amount | 542764 |
| Total Medical Medicare Allowed Amount | 107895.9 |
| Total Medical Medicare Payment Amount | 77436.03 |
| Total Medical Medicare Standardized Payment Amount | 80527.21 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 131 |
| Number Of Beneficiaries Age 65 to 74 | 213 |
| Number Of Beneficiaries Age 75 to 84 | 205 |
| Number Of Beneficiaries Age Greater 84 | 148 |
| Number Of Female Beneficiaries | 386 |
| Number Of Male Beneficiaries | 311 |
| Number Of Non Hispanic White Beneficiaries | 683 |
| Number Of Black or African American Beneficiaries | 0 |
| 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 | |
| Number Of Beneficiaries With Medicare Only Entitlement | 484 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 213 |
| Percent Of With Atrial Fibrillation | 20 |
| Percent Of With Alzheimers Disease or Dementia | 23 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 33 |
| Percent Of With Chronic Kidney Disease | 35 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 11 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.5614 |