| National Provider Identifier [NPI]: | 1992720569 |
| Last Name Of The Provider | KELLER |
| First Name Of The Provider | THOMAS |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2300 WESTERN AVENUE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MANITOWOC |
| Zip Code Of The Provider | 542211450 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 168 |
| Number Of Services | 3807 |
| Number Of Medicare Beneficiaries | 1648 |
| Total Submitted Charge Amount | 605093 |
| Total Medicare Allowed Amount | 98638.52 |
| Total Medicare Payment Amount | 77489.4 |
| Total Medicare Standardized Payment Amount | 81311.37 |
| 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 | 168 |
| Number Of Medical Services | 3807 |
| Number Of Medicare Beneficiaries With Medical Services | 1648 |
| Total Medical Submitted Charge Amount | 605093 |
| Total Medical Medicare Allowed Amount | 98638.52 |
| Total Medical Medicare Payment Amount | 77489.4 |
| Total Medical Medicare Standardized Payment Amount | 81311.37 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 318 |
| Number Of Beneficiaries Age 65 to 74 | 562 |
| Number Of Beneficiaries Age 75 to 84 | 476 |
| Number Of Beneficiaries Age Greater 84 | 292 |
| Number Of Female Beneficiaries | 1112 |
| Number Of Male Beneficiaries | 536 |
| Number Of Non Hispanic White Beneficiaries | 1564 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 35 |
| Number Of Hispanic Beneficiaries | 15 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 16 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1260 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 388 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 22 |
| Percent Of With Chronic Kidney Disease | 29 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.3028 |