| National Provider Identifier [NPI]: | 1790783306 |
| Last Name Of The Provider | FAGAN |
| First Name Of The Provider | DAVID |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 199 S MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | THIENSVILLE |
| Zip Code Of The Provider | 530921902 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 28 |
| Number Of Services | 1273 |
| Number Of Medicare Beneficiaries | 132 |
| Total Submitted Charge Amount | 99600 |
| Total Medicare Allowed Amount | 67962.31 |
| Total Medicare Payment Amount | 46942.67 |
| Total Medicare Standardized Payment Amount | 48859.64 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 58 |
| Number Of Medicare Beneficiaries With Drug Services | 57 |
| Total Drug Submitted ChargeAmount | 1160 |
| Total Drug Medicare AllowedAmount | 698.32 |
| Total Drug Medicare PaymentAmount | 684.4 |
| Total Drug Medicare Standardized Payment Amount | 684.4 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 27 |
| Number Of Medical Services | 1215 |
| Number Of Medicare Beneficiaries With Medical Services | 132 |
| Total Medical Submitted Charge Amount | 98440 |
| Total Medical Medicare Allowed Amount | 67263.99 |
| Total Medical Medicare Payment Amount | 46258.27 |
| Total Medical Medicare Standardized Payment Amount | 48175.24 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 32 |
| Number Of Beneficiaries Age 65 to 74 | 59 |
| Number Of Beneficiaries Age 75 to 84 | 23 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 67 |
| Number Of Male Beneficiaries | 65 |
| Number Of Non Hispanic White Beneficiaries | 119 |
| 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 | |
| Number Of Beneficiaries With Medicare Only Entitlement | 76 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 56 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 42 |
| Percent Of With Hypertension | 46 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 24 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1485 |