| National Provider Identifier [NPI]: | 1033146212 |
| Last Name Of The Provider | JOHNSON |
| First Name Of The Provider | JESSE |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1105 6TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | TRAVERSE CITY |
| Zip Code Of The Provider | 496842345 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 204 |
| Number Of Services | 5934 |
| Number Of Medicare Beneficiaries | 4151 |
| Total Submitted Charge Amount | 462236 |
| Total Medicare Allowed Amount | 161115.55 |
| Total Medicare Payment Amount | 122618.01 |
| Total Medicare Standardized Payment Amount | 126463.75 |
| 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 | 204 |
| Number Of Medical Services | 5934 |
| Number Of Medicare Beneficiaries With Medical Services | 4151 |
| Total Medical Submitted Charge Amount | 462236 |
| Total Medical Medicare Allowed Amount | 161115.55 |
| Total Medical Medicare Payment Amount | 122618.01 |
| Total Medical Medicare Standardized Payment Amount | 126463.75 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 796 |
| Number Of Beneficiaries Age 65 to 74 | 1483 |
| Number Of Beneficiaries Age 75 to 84 | 1272 |
| Number Of Beneficiaries Age Greater 84 | 600 |
| Number Of Female Beneficiaries | 2534 |
| Number Of Male Beneficiaries | 1617 |
| Number Of Non Hispanic White Beneficiaries | 4030 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 18 |
| Number Of American Indian Alaska Native Beneficiaries | 55 |
| Number Of Beneficiaries With Race Not Else where Classified | 33 |
| Number Of Beneficiaries With Medicare Only Entitlement | 3074 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 1077 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 28 |
| Percent Of With Chronic Kidney Disease | 34 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 27 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.4541 |