| National Provider Identifier [NPI]: | 1336122902 |
| Last Name Of The Provider | FOTSO |
| First Name Of The Provider | CARMEN |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 151 DUNDEE AVE |
| Street Address 2 Of The Provider | SUITE C |
| City Of The Provider | EAST DUNDEE |
| Zip Code Of The Provider | 601181648 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 42 |
| Number Of Services | 1435 |
| Number Of Medicare Beneficiaries | 226 |
| Total Submitted Charge Amount | 116284 |
| Total Medicare Allowed Amount | 78673.22 |
| Total Medicare Payment Amount | 52278.84 |
| Total Medicare Standardized Payment Amount | 50717.12 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 76 |
| Number Of Medicare Beneficiaries With Drug Services | 74 |
| Total Drug Submitted ChargeAmount | 4362 |
| Total Drug Medicare AllowedAmount | 2030.64 |
| Total Drug Medicare PaymentAmount | 1819.27 |
| Total Drug Medicare Standardized Payment Amount | 1819.27 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 38 |
| Number Of Medical Services | 1359 |
| Number Of Medicare Beneficiaries With Medical Services | 226 |
| Total Medical Submitted Charge Amount | 111922 |
| Total Medical Medicare Allowed Amount | 76642.58 |
| Total Medical Medicare Payment Amount | 50459.57 |
| Total Medical Medicare Standardized Payment Amount | 48897.85 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 41 |
| Number Of Beneficiaries Age 65 to 74 | 107 |
| Number Of Beneficiaries Age 75 to 84 | 55 |
| Number Of Beneficiaries Age Greater 84 | 23 |
| Number Of Female Beneficiaries | 139 |
| Number Of Male Beneficiaries | 87 |
| Number Of Non Hispanic White Beneficiaries | 116 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 89 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 156 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 70 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 62 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.1102 |