| National Provider Identifier [NPI]: | 1740253061 |
| Last Name Of The Provider | VIDAL |
| First Name Of The Provider | OCTAVIO |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3550 S VELERO ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | CHANDLER |
| Zip Code Of The Provider | 852862681 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 20 |
| Number Of Services | 858 |
| Number Of Medicare Beneficiaries | 676 |
| Total Submitted Charge Amount | 868930 |
| Total Medicare Allowed Amount | 117213.02 |
| Total Medicare Payment Amount | 91245.73 |
| Total Medicare Standardized Payment Amount | 89636.18 |
| 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 | 20 |
| Number Of Medical Services | 858 |
| Number Of Medicare Beneficiaries With Medical Services | 676 |
| Total Medical Submitted Charge Amount | 868930 |
| Total Medical Medicare Allowed Amount | 117213.02 |
| Total Medical Medicare Payment Amount | 91245.73 |
| Total Medical Medicare Standardized Payment Amount | 89636.18 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 189 |
| Number Of Beneficiaries Age 65 to 74 | 178 |
| Number Of Beneficiaries Age 75 to 84 | 171 |
| Number Of Beneficiaries Age Greater 84 | 138 |
| Number Of Female Beneficiaries | 365 |
| Number Of Male Beneficiaries | 311 |
| Number Of Non Hispanic White Beneficiaries | 560 |
| Number Of Black or African American Beneficiaries | 51 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 43 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 366 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 310 |
| Percent Of With Atrial Fibrillation | 22 |
| Percent Of With Alzheimers Disease or Dementia | 32 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 39 |
| Percent Of With Chronic Kidney Disease | 46 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 43 |
| Percent Of With Depression | 47 |
| Percent Of With Diabetes | 43 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 63 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 20 |
| Percent Of With Stroke | 16 |
| Average HCC Risk Score Of Beneficiaries | 2.1771 |