| National Provider Identifier [NPI]: | 1528166717 |
| Last Name Of The Provider | PHILLIPS |
| First Name Of The Provider | WALLACE |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | CRNA |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1031 SCOTT TER |
| Street Address 2 Of The Provider | |
| City Of The Provider | ATHENS |
| Zip Code Of The Provider | 306066271 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | CRNA |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 36 |
| Number Of Services | 351 |
| Number Of Medicare Beneficiaries | 327 |
| Total Submitted Charge Amount | 174879.5 |
| Total Medicare Allowed Amount | 63965.94 |
| Total Medicare Payment Amount | 48292.04 |
| Total Medicare Standardized Payment Amount | 49777.67 |
| 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 | 36 |
| Number Of Medical Services | 351 |
| Number Of Medicare Beneficiaries With Medical Services | 327 |
| Total Medical Submitted Charge Amount | 174879.5 |
| Total Medical Medicare Allowed Amount | 63965.94 |
| Total Medical Medicare Payment Amount | 48292.04 |
| Total Medical Medicare Standardized Payment Amount | 49777.67 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 197 |
| Number Of Beneficiaries Age 75 to 84 | 94 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 171 |
| Number Of Male Beneficiaries | 156 |
| Number Of Non Hispanic White Beneficiaries | 292 |
| 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 | 293 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 34 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 8 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 22 |
| Percent Of With Hyperlipidemia | 72 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 0.866 |