| National Provider Identifier [NPI]: | 1558514109 |
| Last Name Of The Provider | CARLSON |
| First Name Of The Provider | GRACE |
| 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 | 2650 RIDGE AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | EVANSTON |
| Zip Code Of The Provider | 602011718 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 10 |
| Number Of Services | 607 |
| Number Of Medicare Beneficiaries | 250 |
| Total Submitted Charge Amount | 175365 |
| Total Medicare Allowed Amount | 59414.82 |
| Total Medicare Payment Amount | 44547.7 |
| Total Medicare Standardized Payment Amount | 40725.25 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 10 |
| Number Of Medical Services | 607 |
| Number Of Medicare Beneficiaries With Medical Services | 250 |
| Total Medical Submitted Charge Amount | 175365 |
| Total Medical Medicare Allowed Amount | 59414.82 |
| Total Medical Medicare Payment Amount | 44547.7 |
| Total Medical Medicare Standardized Payment Amount | 40725.25 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 52 |
| Number Of Beneficiaries Age 65 to 74 | 70 |
| Number Of Beneficiaries Age 75 to 84 | 51 |
| Number Of Beneficiaries Age Greater 84 | 77 |
| Number Of Female Beneficiaries | 147 |
| Number Of Male Beneficiaries | 103 |
| Number Of Non Hispanic White Beneficiaries | 67 |
| Number Of Black or African American Beneficiaries | 111 |
| Number Of AsianPacific Islander Beneficiaries | 50 |
| 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 | 102 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 148 |
| Percent Of With Atrial Fibrillation | 22 |
| Percent Of With Alzheimers Disease or Dementia | 35 |
| Percent Of With Asthma | 15 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 51 |
| Percent Of With Chronic Kidney Disease | 67 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 28 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 52 |
| Percent Of With Hyperlipidemia | 66 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 53 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 12 |
| Percent Of With Stroke | 14 |
| Average HCC Risk Score Of Beneficiaries | 3.2386 |