| National Provider Identifier [NPI]: | 1639122955 |
| Last Name Of The Provider | FORMAN |
| First Name Of The Provider | EDWARD |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2923 N CALIFORNIA AVE |
| Street Address 2 Of The Provider | SUITE 300 |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606187702 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Orthopedic Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 86 |
| Number Of Services | 862 |
| Number Of Medicare Beneficiaries | 149 |
| Total Submitted Charge Amount | 266477 |
| Total Medicare Allowed Amount | 85716.47 |
| Total Medicare Payment Amount | 66542.68 |
| Total Medicare Standardized Payment Amount | 60486.22 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 100 |
| Number Of Medicare Beneficiaries With Drug Services | 45 |
| Total Drug Submitted ChargeAmount | 5723 |
| Total Drug Medicare AllowedAmount | 4105.03 |
| Total Drug Medicare PaymentAmount | 3218.33 |
| Total Drug Medicare Standardized Payment Amount | 3218.33 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 84 |
| Number Of Medical Services | 762 |
| Number Of Medicare Beneficiaries With Medical Services | 149 |
| Total Medical Submitted Charge Amount | 260754 |
| Total Medical Medicare Allowed Amount | 81611.44 |
| Total Medical Medicare Payment Amount | 63324.35 |
| Total Medical Medicare Standardized Payment Amount | 57267.89 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 20 |
| Number Of Beneficiaries Age 65 to 74 | 66 |
| Number Of Beneficiaries Age 75 to 84 | 45 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 100 |
| Number Of Male Beneficiaries | 49 |
| Number Of Non Hispanic White Beneficiaries | 112 |
| 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 | 90 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 59 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 11 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 40 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1453 |