| National Provider Identifier [NPI]: | 1558312579 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | ELLIOTT |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 200 E 66TH ST APT C904 |
| Street Address 2 Of The Provider | |
| City Of The Provider | NEW YORK |
| Zip Code Of The Provider | 100650163 |
| State Code Of The Provider | NY |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 91 |
| Number Of Services | 2755 |
| Number Of Medicare Beneficiaries | 460 |
| Total Submitted Charge Amount | 309491.82 |
| Total Medicare Allowed Amount | 103242.1 |
| Total Medicare Payment Amount | 79498.63 |
| Total Medicare Standardized Payment Amount | 73400.92 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 2080 |
| Number Of Medicare Beneficiaries With Drug Services | 29 |
| Total Drug Submitted ChargeAmount | 7473 |
| Total Drug Medicare AllowedAmount | 2378.68 |
| Total Drug Medicare PaymentAmount | 1864.88 |
| Total Drug Medicare Standardized Payment Amount | 1864.88 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 88 |
| Number Of Medical Services | 675 |
| Number Of Medicare Beneficiaries With Medical Services | 459 |
| Total Medical Submitted Charge Amount | 302018.82 |
| Total Medical Medicare Allowed Amount | 100863.42 |
| Total Medical Medicare Payment Amount | 77633.75 |
| Total Medical Medicare Standardized Payment Amount | 71536.04 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 83 |
| Number Of Beneficiaries Age 65 to 74 | 214 |
| Number Of Beneficiaries Age 75 to 84 | 116 |
| Number Of Beneficiaries Age Greater 84 | 47 |
| Number Of Female Beneficiaries | 289 |
| Number Of Male Beneficiaries | 171 |
| Number Of Non Hispanic White Beneficiaries | 348 |
| Number Of Black or African American Beneficiaries | 50 |
| Number Of AsianPacific Islander Beneficiaries | 16 |
| Number Of Hispanic Beneficiaries | 35 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 353 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 107 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 45 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.1377 |