| National Provider Identifier [NPI]: | 1780818112 |
| Last Name Of The Provider | DALLEY |
| First Name Of The Provider | ETHAN |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 600 N WOLFE STREET PHIPPS 160 |
| Street Address 2 Of The Provider | |
| City Of The Provider | BALTIMORE |
| Zip Code Of The Provider | 212870001 |
| State Code Of The Provider | MD |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physical Medicine and Rehabilitation |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 50 |
| Number Of Services | 1829 |
| Number Of Medicare Beneficiaries | 166 |
| Total Submitted Charge Amount | 427102.12 |
| Total Medicare Allowed Amount | 128383.92 |
| Total Medicare Payment Amount | 100409.4 |
| Total Medicare Standardized Payment Amount | 103809.37 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 1018 |
| Number Of Medicare Beneficiaries With Drug Services | 71 |
| Total Drug Submitted ChargeAmount | 6230.5 |
| Total Drug Medicare AllowedAmount | 1334 |
| Total Drug Medicare PaymentAmount | 1045.82 |
| Total Drug Medicare Standardized Payment Amount | 1045.82 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 45 |
| Number Of Medical Services | 811 |
| Number Of Medicare Beneficiaries With Medical Services | 166 |
| Total Medical Submitted Charge Amount | 420871.62 |
| Total Medical Medicare Allowed Amount | 127049.92 |
| Total Medical Medicare Payment Amount | 99363.58 |
| Total Medical Medicare Standardized Payment Amount | 102763.55 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 74 |
| Number Of Beneficiaries Age 75 to 84 | 50 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 106 |
| Number Of Male Beneficiaries | 60 |
| Number Of Non Hispanic White Beneficiaries | 123 |
| 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 | 129 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 37 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 22 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 23 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 50 |
| 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 | 1.2016 |