| National Provider Identifier [NPI]: | 1801165592 |
| Last Name Of The Provider | STAY |
| First Name Of The Provider | JACOB |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | RN, BSN, CRNA |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 10375 E MOVIL LAKE RD NE |
| Street Address 2 Of The Provider | |
| City Of The Provider | BEMIDJI |
| Zip Code Of The Provider | 566019786 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | CRNA |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 248 |
| Number Of Medicare Beneficiaries | 233 |
| Total Submitted Charge Amount | 467650 |
| Total Medicare Allowed Amount | 47866.57 |
| Total Medicare Payment Amount | 36377.59 |
| Total Medicare Standardized Payment Amount | 38987.66 |
| 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 | 45 |
| Number Of Medical Services | 248 |
| Number Of Medicare Beneficiaries With Medical Services | 233 |
| Total Medical Submitted Charge Amount | 467650 |
| Total Medical Medicare Allowed Amount | 47866.57 |
| Total Medical Medicare Payment Amount | 36377.59 |
| Total Medical Medicare Standardized Payment Amount | 38987.66 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 39 |
| Number Of Beneficiaries Age 65 to 74 | 93 |
| Number Of Beneficiaries Age 75 to 84 | 72 |
| Number Of Beneficiaries Age Greater 84 | 29 |
| Number Of Female Beneficiaries | 134 |
| Number Of Male Beneficiaries | 99 |
| Number Of Non Hispanic White Beneficiaries | 197 |
| 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 | 184 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 49 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.3692 |