National Provider Identifier [NPI]: |
1023376894 |
Last Name Of The Provider |
THEKKETHOTTIYIL |
First Name Of The Provider |
JOMON |
Middle Initial Of The Provider |
J |
Credentials Of The Provider |
|
Gender Of The Provider |
M |
Entity Type Of The Provider |
I |
Street Address 1 Of The Provider |
4024 CENTRAL AVE |
Street Address 2 Of The Provider |
|
City Of The Provider |
ST PETERSBURG |
Zip Code Of The Provider |
337111239 |
State Code Of The Provider |
FL |
Country Code Of The Provider |
US |
Provider Type Of The Provider |
Licensed Clinical Social Worker |
Medicare Participation Indicator |
Y |
Number Of HCPCS |
4 |
Number Of Services |
1503 |
Number Of Medicare Beneficiaries |
137 |
Total Submitted Charge Amount |
225093 |
Total Medicare Allowed Amount |
146309.31 |
Total Medicare Payment Amount |
113624.55 |
Total Medicare Standardized Payment Amount |
112687.25 |
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 |
4 |
Number Of Medical Services |
1503 |
Number Of Medicare Beneficiaries With Medical Services |
137 |
Total Medical Submitted Charge Amount |
225093 |
Total Medical Medicare Allowed Amount |
146309.31 |
Total Medical Medicare Payment Amount |
113624.55 |
Total Medical Medicare Standardized Payment Amount |
112687.25 |
Average Age Of Beneficiaries |
61 |
Number Of Beneficiaries Age Less65 |
78 |
Number Of Beneficiaries Age 65 to 74 |
33 |
Number Of Beneficiaries Age 75 to 84 |
|
Number Of Beneficiaries Age Greater 84 |
|
Number Of Female Beneficiaries |
85 |
Number Of Male Beneficiaries |
52 |
Number Of Non Hispanic White Beneficiaries |
108 |
Number Of Black or African American Beneficiaries |
|
Number Of AsianPacific Islander Beneficiaries |
|
Number Of Hispanic Beneficiaries |
13 |
Number Of American Indian Alaska Native Beneficiaries |
|
Number Of Beneficiaries With Race Not Else where Classified |
|
Number Of Beneficiaries With Medicare Only Entitlement |
42 |
Number Of Beneficiaries With Medicare Medicaid Entitlement |
95 |
Percent Of With Atrial Fibrillation |
|
Percent Of With Alzheimers Disease or Dementia |
35 |
Percent Of With Asthma |
10 |
Percent Of With Cancer |
|
Percent Of With Heart Failure |
23 |
Percent Of With Chronic Kidney Disease |
31 |
Percent Of With Chronic Obstructive Pulmonary Disease |
30 |
Percent Of With Depression |
75 |
Percent Of With Diabetes |
36 |
Percent Of With Hyperlipidemia |
52 |
Percent Of With Hypertension |
74 |
Percent Of With Ischemic Heart Disease |
53 |
Percent Of With Osteoporosis |
|
Percent Of With Rheumatoid Arthritis Osteoarthritis |
54 |
Percent Of With Schizophrenia Other PsychoticDisorders |
31 |
Percent Of With Stroke |
9 |
Average HCC Risk Score Of Beneficiaries |
1.8012 |