| National Provider Identifier [NPI]: | 1114084431 |
| Last Name Of The Provider | VIDRINE |
| First Name Of The Provider | DUSTIN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 800 E DAWSON ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | TYLER |
| Zip Code Of The Provider | 757012036 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | CRNA |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 63 |
| Number Of Services | 329 |
| Number Of Medicare Beneficiaries | 321 |
| Total Submitted Charge Amount | 374278.8 |
| Total Medicare Allowed Amount | 48132.79 |
| Total Medicare Payment Amount | 37271.97 |
| Total Medicare Standardized Payment Amount | 38666.78 |
| 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 | 63 |
| Number Of Medical Services | 329 |
| Number Of Medicare Beneficiaries With Medical Services | 321 |
| Total Medical Submitted Charge Amount | 374278.8 |
| Total Medical Medicare Allowed Amount | 48132.79 |
| Total Medical Medicare Payment Amount | 37271.97 |
| Total Medical Medicare Standardized Payment Amount | 38666.78 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 56 |
| Number Of Beneficiaries Age 65 to 74 | 154 |
| Number Of Beneficiaries Age 75 to 84 | 88 |
| Number Of Beneficiaries Age Greater 84 | 23 |
| Number Of Female Beneficiaries | 167 |
| Number Of Male Beneficiaries | 154 |
| Number Of Non Hispanic White Beneficiaries | 278 |
| Number Of Black or African American Beneficiaries | 32 |
| 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 | 268 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 53 |
| Percent Of With Atrial Fibrillation | 23 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 34 |
| Percent Of With Chronic Kidney Disease | 34 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 28 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 45 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.7901 |