| National Provider Identifier [NPI]: | 1497792113 |
| Last Name Of The Provider | WHITING |
| First Name Of The Provider | THADDEUS |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2817 NEW PINERY RD |
| Street Address 2 Of The Provider | DIVINE SAVIOR HEALTHCARE, INC. |
| City Of The Provider | PORTAGE |
| Zip Code Of The Provider | 539010387 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 46 |
| Number Of Services | 730 |
| Number Of Medicare Beneficiaries | 277 |
| Total Submitted Charge Amount | 100820.55 |
| Total Medicare Allowed Amount | 50162.36 |
| Total Medicare Payment Amount | 35980.41 |
| Total Medicare Standardized Payment Amount | 38211.53 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 94 |
| Number Of Medicare Beneficiaries With Drug Services | 58 |
| Total Drug Submitted ChargeAmount | 8201.55 |
| Total Drug Medicare AllowedAmount | 4458.81 |
| Total Drug Medicare PaymentAmount | 4118.75 |
| Total Drug Medicare Standardized Payment Amount | 4118.75 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 36 |
| Number Of Medical Services | 636 |
| Number Of Medicare Beneficiaries With Medical Services | 277 |
| Total Medical Submitted Charge Amount | 92619 |
| Total Medical Medicare Allowed Amount | 45703.55 |
| Total Medical Medicare Payment Amount | 31861.66 |
| Total Medical Medicare Standardized Payment Amount | 34092.78 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 57 |
| Number Of Beneficiaries Age 65 to 74 | 110 |
| Number Of Beneficiaries Age 75 to 84 | 68 |
| Number Of Beneficiaries Age Greater 84 | 42 |
| Number Of Female Beneficiaries | 130 |
| Number Of Male Beneficiaries | 147 |
| 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 | 204 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 73 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 12 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 31 |
| Percent Of With Hypertension | 48 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9989 |