| National Provider Identifier [NPI]: | 1366419087 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | CAROLYN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | NP |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1770 E LAKE SHORE DR |
| Street Address 2 Of The Provider | SUITE 207 |
| City Of The Provider | DECATUR |
| Zip Code Of The Provider | 625213832 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 36 |
| Number Of Services | 1041 |
| Number Of Medicare Beneficiaries | 161 |
| Total Submitted Charge Amount | 107215 |
| Total Medicare Allowed Amount | 45971.67 |
| Total Medicare Payment Amount | 33000.37 |
| Total Medicare Standardized Payment Amount | 40507.59 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 47 |
| Number Of Medicare Beneficiaries With Drug Services | 29 |
| Total Drug Submitted ChargeAmount | 1641 |
| Total Drug Medicare AllowedAmount | 749.95 |
| Total Drug Medicare PaymentAmount | 724.86 |
| Total Drug Medicare Standardized Payment Amount | 724.86 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 28 |
| Number Of Medical Services | 994 |
| Number Of Medicare Beneficiaries With Medical Services | 161 |
| Total Medical Submitted Charge Amount | 105574 |
| Total Medical Medicare Allowed Amount | 45221.72 |
| Total Medical Medicare Payment Amount | 32275.51 |
| Total Medical Medicare Standardized Payment Amount | 39782.73 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 31 |
| Number Of Beneficiaries Age 65 to 74 | 66 |
| Number Of Beneficiaries Age 75 to 84 | 49 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 98 |
| Number Of Male Beneficiaries | 63 |
| Number Of Non Hispanic White Beneficiaries | 150 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 127 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 34 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 69 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.959 |