| National Provider Identifier [NPI]: | 1417058256 |
| Last Name Of The Provider | PUTHENVEETIL |
| First Name Of The Provider | ELIZABETH |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1707 N HENDERSON ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | GALESBURG |
| Zip Code Of The Provider | 614011320 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 38 |
| Number Of Services | 500 |
| Number Of Medicare Beneficiaries | 336 |
| Total Submitted Charge Amount | 53257 |
| Total Medicare Allowed Amount | 25098.38 |
| Total Medicare Payment Amount | 16248.09 |
| Total Medicare Standardized Payment Amount | 17201.2 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 19 |
| Number Of Medicare Beneficiaries With Drug Services | 13 |
| Total Drug Submitted ChargeAmount | 503 |
| Total Drug Medicare AllowedAmount | 262 |
| Total Drug Medicare PaymentAmount | 247.74 |
| Total Drug Medicare Standardized Payment Amount | 247.74 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 481 |
| Number Of Medicare Beneficiaries With Medical Services | 336 |
| Total Medical Submitted Charge Amount | 52754 |
| Total Medical Medicare Allowed Amount | 24836.38 |
| Total Medical Medicare Payment Amount | 16000.35 |
| Total Medical Medicare Standardized Payment Amount | 16953.46 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 60 |
| Number Of Beneficiaries Age 65 to 74 | 121 |
| Number Of Beneficiaries Age 75 to 84 | 112 |
| Number Of Beneficiaries Age Greater 84 | 43 |
| Number Of Female Beneficiaries | 216 |
| Number Of Male Beneficiaries | 120 |
| Number Of Non Hispanic White Beneficiaries | 315 |
| 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 | 278 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 58 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9182 |