| National Provider Identifier [NPI]: | 1740425701 |
| Last Name Of The Provider | BOUNMYTHAVONG |
| First Name Of The Provider | SOUPHAPHONE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | CRNA |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2600 GREENBUSH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | LAFAYETTE |
| Zip Code Of The Provider | 479042477 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | CRNA |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 53 |
| Number Of Services | 371 |
| Number Of Medicare Beneficiaries | 358 |
| Total Submitted Charge Amount | 467520 |
| Total Medicare Allowed Amount | 56131.01 |
| Total Medicare Payment Amount | 43761.29 |
| Total Medicare Standardized Payment Amount | 40673.95 |
| 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 | 53 |
| Number Of Medical Services | 371 |
| Number Of Medicare Beneficiaries With Medical Services | 358 |
| Total Medical Submitted Charge Amount | 467520 |
| Total Medical Medicare Allowed Amount | 56131.01 |
| Total Medical Medicare Payment Amount | 43761.29 |
| Total Medical Medicare Standardized Payment Amount | 40673.95 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 35 |
| Number Of Beneficiaries Age 65 to 74 | 147 |
| Number Of Beneficiaries Age 75 to 84 | 138 |
| Number Of Beneficiaries Age Greater 84 | 38 |
| Number Of Female Beneficiaries | 189 |
| Number Of Male Beneficiaries | 169 |
| Number Of Non Hispanic White Beneficiaries | 314 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 22 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 298 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 60 |
| Percent Of With Atrial Fibrillation | 20 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 20 |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 29 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 71 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 49 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.3753 |