| National Provider Identifier [NPI]: | 1922357003 |
| Last Name Of The Provider | BREEN |
| First Name Of The Provider | ETHAN |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | D.O |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 901 OAK PARK BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | PISMO BEACH |
| Zip Code Of The Provider | 934493408 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 29 |
| Number Of Services | 434 |
| Number Of Medicare Beneficiaries | 144 |
| Total Submitted Charge Amount | 77311 |
| Total Medicare Allowed Amount | 34396.8 |
| Total Medicare Payment Amount | 27222.43 |
| Total Medicare Standardized Payment Amount | 26184.06 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 39 |
| Number Of Medicare Beneficiaries With Drug Services | 33 |
| Total Drug Submitted ChargeAmount | 2398 |
| Total Drug Medicare AllowedAmount | 1006.58 |
| Total Drug Medicare PaymentAmount | 985.27 |
| Total Drug Medicare Standardized Payment Amount | 985.27 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 24 |
| Number Of Medical Services | 395 |
| Number Of Medicare Beneficiaries With Medical Services | 144 |
| Total Medical Submitted Charge Amount | 74913 |
| Total Medical Medicare Allowed Amount | 33390.22 |
| Total Medical Medicare Payment Amount | 26237.16 |
| Total Medical Medicare Standardized Payment Amount | 25198.79 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 12 |
| Number Of Beneficiaries Age 65 to 74 | 71 |
| Number Of Beneficiaries Age 75 to 84 | 40 |
| Number Of Beneficiaries Age Greater 84 | 21 |
| Number Of Female Beneficiaries | 81 |
| Number Of Male Beneficiaries | 63 |
| 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 | 133 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 11 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 49 |
| Percent Of With Hypertension | 64 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0648 |