| National Provider Identifier [NPI]: | 1689732810 |
| Last Name Of The Provider | MORTIMER |
| First Name Of The Provider | MARTY |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 517 E DIVISION ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | ROCKFORD |
| Zip Code Of The Provider | 493411376 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 37 |
| Number Of Services | 511 |
| Number Of Medicare Beneficiaries | 113 |
| Total Submitted Charge Amount | 32176.78 |
| Total Medicare Allowed Amount | 14418.43 |
| Total Medicare Payment Amount | 9016.32 |
| Total Medicare Standardized Payment Amount | 11923.43 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 15 |
| Number Of Drug Services | 237 |
| Number Of Medicare Beneficiaries With Drug Services | 36 |
| Total Drug Submitted ChargeAmount | 2152.78 |
| Total Drug Medicare AllowedAmount | 561.36 |
| Total Drug Medicare PaymentAmount | 371.37 |
| Total Drug Medicare Standardized Payment Amount | 371.37 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 22 |
| Number Of Medical Services | 274 |
| Number Of Medicare Beneficiaries With Medical Services | 112 |
| Total Medical Submitted Charge Amount | 30024 |
| Total Medical Medicare Allowed Amount | 13857.07 |
| Total Medical Medicare Payment Amount | 8644.95 |
| Total Medical Medicare Standardized Payment Amount | 11552.06 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 19 |
| Number Of Beneficiaries Age 65 to 74 | 55 |
| Number Of Beneficiaries Age 75 to 84 | 25 |
| Number Of Beneficiaries Age Greater 84 | 14 |
| Number Of Female Beneficiaries | 67 |
| Number Of Male Beneficiaries | 46 |
| Number Of Non Hispanic White Beneficiaries | 102 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 97 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 16 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 19 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 27 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 49 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0841 |