| National Provider Identifier [NPI]: | 1275525875 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | DANIEL |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2680 LEONARD NE |
| Street Address 2 Of The Provider | |
| City Of The Provider | GRAND RAPIDS |
| Zip Code Of The Provider | 49525 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 28 |
| Number Of Services | 240 |
| Number Of Medicare Beneficiaries | 62 |
| Total Submitted Charge Amount | 14778.42 |
| Total Medicare Allowed Amount | 9314.06 |
| Total Medicare Payment Amount | 7247.9 |
| Total Medicare Standardized Payment Amount | 7503.55 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 25 |
| Number Of Medicare Beneficiaries With Drug Services | 19 |
| Total Drug Submitted ChargeAmount | 831.92 |
| Total Drug Medicare AllowedAmount | 830.22 |
| Total Drug Medicare PaymentAmount | 811 |
| Total Drug Medicare Standardized Payment Amount | 811 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 20 |
| Number Of Medical Services | 215 |
| Number Of Medicare Beneficiaries With Medical Services | 62 |
| Total Medical Submitted Charge Amount | 13946.5 |
| Total Medical Medicare Allowed Amount | 8483.84 |
| Total Medical Medicare Payment Amount | 6436.9 |
| Total Medical Medicare Standardized Payment Amount | 6692.55 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 37 |
| Number Of Beneficiaries Age 75 to 84 | 14 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 39 |
| Number Of Male Beneficiaries | 23 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 23 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9444 |