| National Provider Identifier [NPI]: | 1821016957 |
| Last Name Of The Provider | KIM |
| First Name Of The Provider | DONGSOO |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | D.D.S., M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1501 KINGS HWY |
| Street Address 2 Of The Provider | DEPARTMENT OF ORAL SURGERY |
| City Of The Provider | SHREVEPORT |
| Zip Code Of The Provider | 711034228 |
| State Code Of The Provider | LA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Maxillofacial Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 81 |
| Number Of Services | 356 |
| Number Of Medicare Beneficiaries | 121 |
| Total Submitted Charge Amount | 416064 |
| Total Medicare Allowed Amount | 74844.35 |
| Total Medicare Payment Amount | 57593.37 |
| Total Medicare Standardized Payment Amount | 60056.24 |
| 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 | 81 |
| Number Of Medical Services | 356 |
| Number Of Medicare Beneficiaries With Medical Services | 121 |
| Total Medical Submitted Charge Amount | 416064 |
| Total Medical Medicare Allowed Amount | 74844.35 |
| Total Medical Medicare Payment Amount | 57593.37 |
| Total Medical Medicare Standardized Payment Amount | 60056.24 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 36 |
| Number Of Beneficiaries Age 65 to 74 | 39 |
| Number Of Beneficiaries Age 75 to 84 | 31 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 67 |
| Number Of Male Beneficiaries | 54 |
| Number Of Non Hispanic White Beneficiaries | 92 |
| 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 | 91 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 30 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 17 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.3443 |