| National Provider Identifier [NPI]: | 1700862992 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | THOMAS |
| Middle Initial Of The Provider | V |
| Credentials Of The Provider | MD |
| 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 | 539019257 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 20 |
| Number Of Services | 664 |
| Number Of Medicare Beneficiaries | 440 |
| Total Submitted Charge Amount | 385754.25 |
| Total Medicare Allowed Amount | 54609.58 |
| Total Medicare Payment Amount | 38695.38 |
| Total Medicare Standardized Payment Amount | 40220.48 |
| 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 | 20 |
| Number Of Medical Services | 664 |
| Number Of Medicare Beneficiaries With Medical Services | 440 |
| Total Medical Submitted Charge Amount | 385754.25 |
| Total Medical Medicare Allowed Amount | 54609.58 |
| Total Medical Medicare Payment Amount | 38695.38 |
| Total Medical Medicare Standardized Payment Amount | 40220.48 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 102 |
| Number Of Beneficiaries Age 65 to 74 | 126 |
| Number Of Beneficiaries Age 75 to 84 | 117 |
| Number Of Beneficiaries Age Greater 84 | 95 |
| Number Of Female Beneficiaries | 250 |
| Number Of Male Beneficiaries | 190 |
| Number Of Non Hispanic White Beneficiaries | 425 |
| Number Of Black or African American Beneficiaries | 0 |
| 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 | 287 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 153 |
| Percent Of With Atrial Fibrillation | 16 |
| Percent Of With Alzheimers Disease or Dementia | 15 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 29 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 42 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 29 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.416 |