| National Provider Identifier [NPI]: | 1740207547 |
| Last Name Of The Provider | IDSTEN |
| First Name Of The Provider | WILFRED |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3001 W DR MARTIN LUTHER KING JR BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | TAMPA |
| Zip Code Of The Provider | 336076307 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 13 |
| Number Of Services | 441 |
| Number Of Medicare Beneficiaries | 237 |
| Total Submitted Charge Amount | 200552 |
| Total Medicare Allowed Amount | 47351.66 |
| Total Medicare Payment Amount | 36498.32 |
| Total Medicare Standardized Payment Amount | 34860.92 |
| 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 | 13 |
| Number Of Medical Services | 441 |
| Number Of Medicare Beneficiaries With Medical Services | 237 |
| Total Medical Submitted Charge Amount | 200552 |
| Total Medical Medicare Allowed Amount | 47351.66 |
| Total Medical Medicare Payment Amount | 36498.32 |
| Total Medical Medicare Standardized Payment Amount | 34860.92 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 92 |
| Number Of Beneficiaries Age 65 to 74 | 78 |
| Number Of Beneficiaries Age 75 to 84 | 45 |
| Number Of Beneficiaries Age Greater 84 | 22 |
| Number Of Female Beneficiaries | 129 |
| Number Of Male Beneficiaries | 108 |
| Number Of Non Hispanic White Beneficiaries | 20 |
| Number Of Black or African American Beneficiaries | 114 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 89 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 20 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 217 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 24 |
| Percent Of With Asthma | 21 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 44 |
| Percent Of With Chronic Kidney Disease | 43 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 31 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 54 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 68 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 20 |
| Percent Of With Stroke | 14 |
| Average HCC Risk Score Of Beneficiaries | 2.6404 |