| National Provider Identifier [NPI]: | 1205945276 |
| Last Name Of The Provider | FORTIN |
| First Name Of The Provider | JEAN |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2800 ROSS CLARK CIRCLE |
| Street Address 2 Of The Provider | |
| City Of The Provider | DOTHAN |
| Zip Code Of The Provider | 36301 |
| State Code Of The Provider | AL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Ophthalmology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 52 |
| Number Of Services | 11621 |
| Number Of Medicare Beneficiaries | 1571 |
| Total Submitted Charge Amount | 2839150.8 |
| Total Medicare Allowed Amount | 1756393.66 |
| Total Medicare Payment Amount | 1338699.71 |
| Total Medicare Standardized Payment Amount | 1385594.02 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 4490 |
| Number Of Medicare Beneficiaries With Drug Services | 321 |
| Total Drug Submitted ChargeAmount | 1362586.8 |
| Total Drug Medicare AllowedAmount | 1114989.26 |
| Total Drug Medicare PaymentAmount | 873685.74 |
| Total Drug Medicare Standardized Payment Amount | 873685.74 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 45 |
| Number Of Medical Services | 7131 |
| Number Of Medicare Beneficiaries With Medical Services | 1571 |
| Total Medical Submitted Charge Amount | 1476564 |
| Total Medical Medicare Allowed Amount | 641404.4 |
| Total Medical Medicare Payment Amount | 465013.97 |
| Total Medical Medicare Standardized Payment Amount | 511908.28 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 145 |
| Number Of Beneficiaries Age 65 to 74 | 546 |
| Number Of Beneficiaries Age 75 to 84 | 595 |
| Number Of Beneficiaries Age Greater 84 | 285 |
| Number Of Female Beneficiaries | 921 |
| Number Of Male Beneficiaries | 650 |
| Number Of Non Hispanic White Beneficiaries | 1288 |
| Number Of Black or African American Beneficiaries | 257 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 13 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 1247 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 324 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 21 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 51 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 43 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.343 |