| National Provider Identifier [NPI]: | 1124071915 |
| Last Name Of The Provider | PORTNER |
| First Name Of The Provider | SUSAN |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | RPT |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4121 VETERANS MEMORIAL DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | MOUNT VERNON |
| Zip Code Of The Provider | 628646262 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physical Therapist |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 14 |
| Number Of Services | 1955 |
| Number Of Medicare Beneficiaries | 287 |
| Total Submitted Charge Amount | 148961 |
| Total Medicare Allowed Amount | 51634.71 |
| Total Medicare Payment Amount | 39820.32 |
| Total Medicare Standardized Payment Amount | 30983.38 |
| 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 | 14 |
| Number Of Medical Services | 1955 |
| Number Of Medicare Beneficiaries With Medical Services | 287 |
| Total Medical Submitted Charge Amount | 148961 |
| Total Medical Medicare Allowed Amount | 51634.71 |
| Total Medical Medicare Payment Amount | 39820.32 |
| Total Medical Medicare Standardized Payment Amount | 30983.38 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 53 |
| Number Of Beneficiaries Age 65 to 74 | 141 |
| Number Of Beneficiaries Age 75 to 84 | 77 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 170 |
| Number Of Male Beneficiaries | 117 |
| Number Of Non Hispanic White Beneficiaries | 273 |
| 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 | 219 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 68 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 37 |
| Percent Of With Hyperlipidemia | 62 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 42 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 68 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.1698 |