| National Provider Identifier [NPI]: | 1124078357 |
| Last Name Of The Provider | TESSALEE |
| First Name Of The Provider | DAPHNE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 5101 WILLOW SPRINGS RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | LA GRANGE |
| Zip Code Of The Provider | 605252600 |
| 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 | 26 |
| Number Of Services | 272 |
| Number Of Medicare Beneficiaries | 141 |
| Total Submitted Charge Amount | 48068 |
| Total Medicare Allowed Amount | 23505.73 |
| Total Medicare Payment Amount | 17821.04 |
| Total Medicare Standardized Payment Amount | 16679.8 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 15 |
| Number Of Medicare Beneficiaries With Drug Services | 14 |
| Total Drug Submitted ChargeAmount | 728 |
| Total Drug Medicare AllowedAmount | 358.84 |
| Total Drug Medicare PaymentAmount | 344.69 |
| Total Drug Medicare Standardized Payment Amount | 344.69 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 257 |
| Number Of Medicare Beneficiaries With Medical Services | 141 |
| Total Medical Submitted Charge Amount | 47340 |
| Total Medical Medicare Allowed Amount | 23146.89 |
| Total Medical Medicare Payment Amount | 17476.35 |
| Total Medical Medicare Standardized Payment Amount | 16335.11 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 33 |
| Number Of Beneficiaries Age 65 to 74 | 44 |
| Number Of Beneficiaries Age 75 to 84 | 41 |
| Number Of Beneficiaries Age Greater 84 | 23 |
| Number Of Female Beneficiaries | 89 |
| Number Of Male Beneficiaries | 52 |
| Number Of Non Hispanic White Beneficiaries | 113 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 13 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 103 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 38 |
| Percent Of With Atrial Fibrillation | 22 |
| Percent Of With Alzheimers Disease or Dementia | 18 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 28 |
| Percent Of With Chronic Kidney Disease | 29 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 37 |
| Percent Of With Diabetes | 40 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.7019 |