| National Provider Identifier [NPI]: | 1770561813 |
| Last Name Of The Provider | CUSTIS |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 24900 SE STARK |
| Street Address 2 Of The Provider | STE 109 |
| City Of The Provider | GRESHAM |
| Zip Code Of The Provider | 97030 |
| State Code Of The Provider | OR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 32 |
| Number Of Services | 1703 |
| Number Of Medicare Beneficiaries | 530 |
| Total Submitted Charge Amount | 230391 |
| Total Medicare Allowed Amount | 93018.57 |
| Total Medicare Payment Amount | 68178.37 |
| Total Medicare Standardized Payment Amount | 67446.44 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 91 |
| Number Of Medicare Beneficiaries With Drug Services | 85 |
| Total Drug Submitted ChargeAmount | 1805 |
| Total Drug Medicare AllowedAmount | 1513.99 |
| Total Drug Medicare PaymentAmount | 1430.79 |
| Total Drug Medicare Standardized Payment Amount | 1430.79 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 28 |
| Number Of Medical Services | 1612 |
| Number Of Medicare Beneficiaries With Medical Services | 530 |
| Total Medical Submitted Charge Amount | 228586 |
| Total Medical Medicare Allowed Amount | 91504.58 |
| Total Medical Medicare Payment Amount | 66747.58 |
| Total Medical Medicare Standardized Payment Amount | 66015.65 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 70 |
| Number Of Beneficiaries Age 65 to 74 | 184 |
| Number Of Beneficiaries Age 75 to 84 | 183 |
| Number Of Beneficiaries Age Greater 84 | 93 |
| Number Of Female Beneficiaries | 275 |
| Number Of Male Beneficiaries | 255 |
| Number Of Non Hispanic White Beneficiaries | 484 |
| Number Of Black or African American Beneficiaries | 11 |
| Number Of AsianPacific Islander Beneficiaries | 11 |
| 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 | 422 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 108 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 37 |
| Percent Of With Chronic Kidney Disease | 43 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 21 |
| Percent Of With Depression | 23 |
| Percent Of With Diabetes | 39 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 42 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.7668 |