| National Provider Identifier [NPI]: | 1164661674 |
| Last Name Of The Provider | TIDWELL |
| First Name Of The Provider | RANDY |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | APN |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 421 N BROADWAY |
| Street Address 2 Of The Provider | |
| City Of The Provider | PORTLAND |
| Zip Code Of The Provider | 371481750 |
| State Code Of The Provider | TN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 48 |
| Number Of Services | 675 |
| Number Of Medicare Beneficiaries | 100 |
| Total Submitted Charge Amount | 42092 |
| Total Medicare Allowed Amount | 19688.69 |
| Total Medicare Payment Amount | 12618.75 |
| Total Medicare Standardized Payment Amount | 16614.57 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 259 |
| Number Of Medicare Beneficiaries With Drug Services | 46 |
| Total Drug Submitted ChargeAmount | 8466 |
| Total Drug Medicare AllowedAmount | 323.77 |
| Total Drug Medicare PaymentAmount | 259.44 |
| Total Drug Medicare Standardized Payment Amount | 259.44 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 39 |
| Number Of Medical Services | 416 |
| Number Of Medicare Beneficiaries With Medical Services | 100 |
| Total Medical Submitted Charge Amount | 33626 |
| Total Medical Medicare Allowed Amount | 19364.92 |
| Total Medical Medicare Payment Amount | 12359.31 |
| Total Medical Medicare Standardized Payment Amount | 16355.13 |
| Average Age Of Beneficiaries | 63 |
| Number Of Beneficiaries Age Less65 | 43 |
| Number Of Beneficiaries Age 65 to 74 | 38 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 59 |
| Number Of Male Beneficiaries | 41 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| 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 | 62 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 38 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 37 |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 29 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0773 |