| National Provider Identifier [NPI]: | 1154642585 |
| Last Name Of The Provider | CLARK |
| First Name Of The Provider | JESSE |
| Middle Initial Of The Provider | N |
| Credentials Of The Provider | DO |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 10122 E. 10TH STREET |
| Street Address 2 Of The Provider | SUITE 100 |
| City Of The Provider | INDIANAPOLIS |
| Zip Code Of The Provider | 462292697 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Interventional Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 42 |
| Number Of Services | 503 |
| Number Of Medicare Beneficiaries | 236 |
| Total Submitted Charge Amount | 53401 |
| Total Medicare Allowed Amount | 36477.71 |
| Total Medicare Payment Amount | 26660.3 |
| Total Medicare Standardized Payment Amount | 28018.61 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 20 |
| Number Of Medicare Beneficiaries With Drug Services | 16 |
| Total Drug Submitted ChargeAmount | 827 |
| Total Drug Medicare AllowedAmount | 475.55 |
| Total Drug Medicare PaymentAmount | 464.96 |
| Total Drug Medicare Standardized Payment Amount | 464.96 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 36 |
| Number Of Medical Services | 483 |
| Number Of Medicare Beneficiaries With Medical Services | 236 |
| Total Medical Submitted Charge Amount | 52574 |
| Total Medical Medicare Allowed Amount | 36002.16 |
| Total Medical Medicare Payment Amount | 26195.34 |
| Total Medical Medicare Standardized Payment Amount | 27553.65 |
| Average Age Of Beneficiaries | 62 |
| Number Of Beneficiaries Age Less65 | 119 |
| Number Of Beneficiaries Age 65 to 74 | 54 |
| Number Of Beneficiaries Age 75 to 84 | 39 |
| Number Of Beneficiaries Age Greater 84 | 24 |
| Number Of Female Beneficiaries | 149 |
| Number Of Male Beneficiaries | 87 |
| Number Of Non Hispanic White Beneficiaries | 145 |
| 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 | 80 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 156 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 17 |
| Percent Of With Asthma | 19 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 28 |
| Percent Of With Chronic Kidney Disease | 34 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 26 |
| Percent Of With Depression | 42 |
| Percent Of With Diabetes | 46 |
| Percent Of With Hyperlipidemia | 47 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 17 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.9275 |