| National Provider Identifier [NPI]: | 1003087776 |
| Last Name Of The Provider | KELLY |
| First Name Of The Provider | THERESA |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | CRNA |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 601 PARK ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | HONESDALE |
| Zip Code Of The Provider | 184311445 |
| State Code Of The Provider | PA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | CRNA |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 9 |
| Number Of Services | 1059 |
| Number Of Medicare Beneficiaries | 1019 |
| Total Submitted Charge Amount | 501525 |
| Total Medicare Allowed Amount | 142434.57 |
| Total Medicare Payment Amount | 105166.69 |
| Total Medicare Standardized Payment Amount | 106870.55 |
| 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 | 9 |
| Number Of Medical Services | 1059 |
| Number Of Medicare Beneficiaries With Medical Services | 1019 |
| Total Medical Submitted Charge Amount | 501525 |
| Total Medical Medicare Allowed Amount | 142434.57 |
| Total Medical Medicare Payment Amount | 105166.69 |
| Total Medical Medicare Standardized Payment Amount | 106870.55 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 126 |
| Number Of Beneficiaries Age 65 to 74 | 609 |
| Number Of Beneficiaries Age 75 to 84 | 258 |
| Number Of Beneficiaries Age Greater 84 | 26 |
| Number Of Female Beneficiaries | 592 |
| Number Of Male Beneficiaries | 427 |
| Number Of Non Hispanic White Beneficiaries | 977 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 17 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 12 |
| Number Of Beneficiaries With Medicare Only Entitlement | 901 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 118 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 2 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 1 |
| Percent Of With Stroke | 2 |
| Average HCC Risk Score Of Beneficiaries | 0.9105 |