| National Provider Identifier [NPI]: | 1063640563 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | SANDRA |
| Middle Initial Of The Provider | N |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1653 W CONGRESS PKWY |
| Street Address 2 Of The Provider | |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606123833 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 1401 |
| Number Of Medicare Beneficiaries | 181 |
| Total Submitted Charge Amount | 121629 |
| Total Medicare Allowed Amount | 63723.83 |
| Total Medicare Payment Amount | 43354.84 |
| Total Medicare Standardized Payment Amount | 46083.02 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 478 |
| Number Of Medicare Beneficiaries With Drug Services | 48 |
| Total Drug Submitted ChargeAmount | 12036 |
| Total Drug Medicare AllowedAmount | 3237.99 |
| Total Drug Medicare PaymentAmount | 2871.51 |
| Total Drug Medicare Standardized Payment Amount | 2871.51 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 36 |
| Number Of Medical Services | 923 |
| Number Of Medicare Beneficiaries With Medical Services | 181 |
| Total Medical Submitted Charge Amount | 109593 |
| Total Medical Medicare Allowed Amount | 60485.84 |
| Total Medical Medicare Payment Amount | 40483.33 |
| Total Medical Medicare Standardized Payment Amount | 43211.51 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 59 |
| Number Of Beneficiaries Age 65 to 74 | 63 |
| Number Of Beneficiaries Age 75 to 84 | 44 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 127 |
| Number Of Male Beneficiaries | 54 |
| Number Of Non Hispanic White Beneficiaries | 151 |
| 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 | 100 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 81 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 29 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.4202 |