| National Provider Identifier [NPI]: | 1285621516 |
| Last Name Of The Provider | PETERSEN |
| First Name Of The Provider | JON |
| Middle Initial Of The Provider | F |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1301 S KOKE MILL RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | SPRINGFIELD |
| Zip Code Of The Provider | 627119252 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Preventive Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 5 |
| Number Of Services | 526 |
| Number Of Medicare Beneficiaries | 264 |
| Total Submitted Charge Amount | 19383 |
| Total Medicare Allowed Amount | 11689.12 |
| Total Medicare Payment Amount | 11435.34 |
| Total Medicare Standardized Payment Amount | 12102.19 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 263 |
| Number Of Medicare Beneficiaries With Drug Services | 263 |
| Total Drug Submitted ChargeAmount | 9998 |
| Total Drug Medicare AllowedAmount | 5701.93 |
| Total Drug Medicare PaymentAmount | 5587.66 |
| Total Drug Medicare Standardized Payment Amount | 5587.66 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 2 |
| Number Of Medical Services | 263 |
| Number Of Medicare Beneficiaries With Medical Services | 263 |
| Total Medical Submitted Charge Amount | 9385 |
| Total Medical Medicare Allowed Amount | 5987.19 |
| Total Medical Medicare Payment Amount | 5847.68 |
| Total Medical Medicare Standardized Payment Amount | 6514.53 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 84 |
| Number Of Beneficiaries Age 65 to 74 | 128 |
| Number Of Beneficiaries Age 75 to 84 | 41 |
| Number Of Beneficiaries Age Greater 84 | 11 |
| Number Of Female Beneficiaries | 172 |
| Number Of Male Beneficiaries | 92 |
| Number Of Non Hispanic White Beneficiaries | 207 |
| Number Of Black or African American Beneficiaries | 35 |
| 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 | 194 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 70 |
| Percent Of With Atrial Fibrillation | 4 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 31 |
| Percent Of With Diabetes | 22 |
| Percent Of With Hyperlipidemia | 40 |
| Percent Of With Hypertension | 58 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.096 |