| National Provider Identifier [NPI]: | 1912942822 |
| Last Name Of The Provider | BUBOLTZ |
| First Name Of The Provider | JEROME |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1032 E SUMNER ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | HARTFORD |
| Zip Code Of The Provider | 530271608 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 29 |
| Number Of Services | 1752 |
| Number Of Medicare Beneficiaries | 196 |
| Total Submitted Charge Amount | 772224 |
| Total Medicare Allowed Amount | 101864.76 |
| Total Medicare Payment Amount | 76444.75 |
| Total Medicare Standardized Payment Amount | 80658.45 |
| 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 | 29 |
| Number Of Medical Services | 1752 |
| Number Of Medicare Beneficiaries With Medical Services | 196 |
| Total Medical Submitted Charge Amount | 772224 |
| Total Medical Medicare Allowed Amount | 101864.76 |
| Total Medical Medicare Payment Amount | 76444.75 |
| Total Medical Medicare Standardized Payment Amount | 80658.45 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 45 |
| Number Of Beneficiaries Age 65 to 74 | 62 |
| Number Of Beneficiaries Age 75 to 84 | 62 |
| Number Of Beneficiaries Age Greater 84 | 27 |
| Number Of Female Beneficiaries | 93 |
| Number Of Male Beneficiaries | 103 |
| Number Of Non Hispanic White Beneficiaries | 181 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 135 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 61 |
| Percent Of With Atrial Fibrillation | 30 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 54 |
| Percent Of With Chronic Kidney Disease | 59 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 64 |
| Percent Of With Hyperlipidemia | 68 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 55 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 3.1909 |