| National Provider Identifier [NPI]: | 1164497731 |
| Last Name Of The Provider | CHARLETTA |
| First Name Of The Provider | DALE |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4800 S GREENWOOD AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606151914 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 18 |
| Number Of Services | 496 |
| Number Of Medicare Beneficiaries | 439 |
| Total Submitted Charge Amount | 117436.32 |
| Total Medicare Allowed Amount | 42675.62 |
| Total Medicare Payment Amount | 33394.29 |
| Total Medicare Standardized Payment Amount | 31164.65 |
| 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 | 18 |
| Number Of Medical Services | 496 |
| Number Of Medicare Beneficiaries With Medical Services | 439 |
| Total Medical Submitted Charge Amount | 117436.32 |
| Total Medical Medicare Allowed Amount | 42675.62 |
| Total Medical Medicare Payment Amount | 33394.29 |
| Total Medical Medicare Standardized Payment Amount | 31164.65 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 28 |
| Number Of Beneficiaries Age 65 to 74 | 197 |
| Number Of Beneficiaries Age 75 to 84 | 171 |
| Number Of Beneficiaries Age Greater 84 | 43 |
| Number Of Female Beneficiaries | 284 |
| Number Of Male Beneficiaries | 155 |
| Number Of Non Hispanic White Beneficiaries | 364 |
| Number Of Black or African American Beneficiaries | 39 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 24 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 409 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 30 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 5 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 35 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.0694 |