| National Provider Identifier [NPI]: | 1114933744 |
| Last Name Of The Provider | DETLIE |
| First Name Of The Provider | ELIZABETH |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 404 HIGHWAY 96 W |
| Street Address 2 Of The Provider | |
| City Of The Provider | SHOREVIEW |
| Zip Code Of The Provider | 551261900 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 49 |
| Number Of Services | 741 |
| Number Of Medicare Beneficiaries | 108 |
| Total Submitted Charge Amount | 57542 |
| Total Medicare Allowed Amount | 30054.85 |
| Total Medicare Payment Amount | 20713.09 |
| Total Medicare Standardized Payment Amount | 21310.38 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 47 |
| Number Of Medicare Beneficiaries With Drug Services | 32 |
| Total Drug Submitted ChargeAmount | 1444 |
| Total Drug Medicare AllowedAmount | 1093.57 |
| Total Drug Medicare PaymentAmount | 1030.14 |
| Total Drug Medicare Standardized Payment Amount | 1030.14 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 41 |
| Number Of Medical Services | 694 |
| Number Of Medicare Beneficiaries With Medical Services | 108 |
| Total Medical Submitted Charge Amount | 56098 |
| Total Medical Medicare Allowed Amount | 28961.28 |
| Total Medical Medicare Payment Amount | 19682.95 |
| Total Medical Medicare Standardized Payment Amount | 20280.24 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 24 |
| Number Of Beneficiaries Age 65 to 74 | 31 |
| Number Of Beneficiaries Age 75 to 84 | 38 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 93 |
| Number Of Male Beneficiaries | 15 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 87 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 21 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 18 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 17 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 28 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0022 |