| National Provider Identifier [NPI]: | 1104923721 |
| Last Name Of The Provider | TE |
| First Name Of The Provider | HIANTO |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1221 N MAY |
| Street Address 2 Of The Provider | |
| City Of The Provider | GUYMON |
| Zip Code Of The Provider | 739421948 |
| State Code Of The Provider | OK |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | General Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 68 |
| Number Of Services | 2044 |
| Number Of Medicare Beneficiaries | 241 |
| Total Submitted Charge Amount | 275705 |
| Total Medicare Allowed Amount | 127158.05 |
| Total Medicare Payment Amount | 91532.96 |
| Total Medicare Standardized Payment Amount | 103284.16 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 400 |
| Number Of Medicare Beneficiaries With Drug Services | 86 |
| Total Drug Submitted ChargeAmount | 10865 |
| Total Drug Medicare AllowedAmount | 802.68 |
| Total Drug Medicare PaymentAmount | 721.82 |
| Total Drug Medicare Standardized Payment Amount | 721.82 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 64 |
| Number Of Medical Services | 1644 |
| Number Of Medicare Beneficiaries With Medical Services | 241 |
| Total Medical Submitted Charge Amount | 264840 |
| Total Medical Medicare Allowed Amount | 126355.37 |
| Total Medical Medicare Payment Amount | 90811.14 |
| Total Medical Medicare Standardized Payment Amount | 102562.34 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 28 |
| Number Of Beneficiaries Age 65 to 74 | 101 |
| Number Of Beneficiaries Age 75 to 84 | 83 |
| Number Of Beneficiaries Age Greater 84 | 29 |
| Number Of Female Beneficiaries | 129 |
| Number Of Male Beneficiaries | 112 |
| Number Of Non Hispanic White Beneficiaries | 183 |
| 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 | 199 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 42 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 21 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 13 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0138 |