| National Provider Identifier [NPI]: | 1679725337 |
| Last Name Of The Provider | NICHOLSON |
| First Name Of The Provider | EDWARD |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | D.O |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 12021 S HARLEM AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | PALOS HEIGHTS |
| Zip Code Of The Provider | 604631139 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | General Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 23 |
| Number Of Services | 1107 |
| Number Of Medicare Beneficiaries | 135 |
| Total Submitted Charge Amount | 114574 |
| Total Medicare Allowed Amount | 104940.23 |
| Total Medicare Payment Amount | 83736.46 |
| Total Medicare Standardized Payment Amount | 78641.66 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 79 |
| Number Of Medicare Beneficiaries With Drug Services | 38 |
| Total Drug Submitted ChargeAmount | 1115 |
| Total Drug Medicare AllowedAmount | 451.37 |
| Total Drug Medicare PaymentAmount | 419.74 |
| Total Drug Medicare Standardized Payment Amount | 419.74 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 18 |
| Number Of Medical Services | 1028 |
| Number Of Medicare Beneficiaries With Medical Services | 135 |
| Total Medical Submitted Charge Amount | 113459 |
| Total Medical Medicare Allowed Amount | 104488.86 |
| Total Medical Medicare Payment Amount | 83316.72 |
| Total Medical Medicare Standardized Payment Amount | 78221.92 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 44 |
| Number Of Beneficiaries Age 65 to 74 | 39 |
| Number Of Beneficiaries Age 75 to 84 | 35 |
| Number Of Beneficiaries Age Greater 84 | 17 |
| Number Of Female Beneficiaries | 93 |
| Number Of Male Beneficiaries | 42 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | 105 |
| 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 | 49 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 86 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 22 |
| Percent Of With Asthma | 24 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 50 |
| Percent Of With Chronic Kidney Disease | 39 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 29 |
| Percent Of With Depression | 47 |
| Percent Of With Diabetes | 70 |
| Percent Of With Hyperlipidemia | 75 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 56 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 15 |
| Average HCC Risk Score Of Beneficiaries | 1.6744 |