| National Provider Identifier [NPI]: | 1700865193 |
| Last Name Of The Provider | SUDBERRY |
| First Name Of The Provider | JONATHAN |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6500 EXCELSIOR BLVD |
| Street Address 2 Of The Provider | METHODIST HOSPITAL, 2ND FLOOR RADIOLOGY |
| City Of The Provider | ST LOUIS PARK |
| Zip Code Of The Provider | 554264702 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 122 |
| Number Of Services | 8214 |
| Number Of Medicare Beneficiaries | 1256 |
| Total Submitted Charge Amount | 278130.4 |
| Total Medicare Allowed Amount | 113538.86 |
| Total Medicare Payment Amount | 82890.54 |
| Total Medicare Standardized Payment Amount | 86299.27 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 6526 |
| Number Of Medicare Beneficiaries With Drug Services | 69 |
| Total Drug Submitted ChargeAmount | 3208.25 |
| Total Drug Medicare AllowedAmount | 1671.44 |
| Total Drug Medicare PaymentAmount | 1247.32 |
| Total Drug Medicare Standardized Payment Amount | 1247.32 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 117 |
| Number Of Medical Services | 1688 |
| Number Of Medicare Beneficiaries With Medical Services | 1256 |
| Total Medical Submitted Charge Amount | 274922.15 |
| Total Medical Medicare Allowed Amount | 111867.42 |
| Total Medical Medicare Payment Amount | 81643.22 |
| Total Medical Medicare Standardized Payment Amount | 85051.95 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 301 |
| Number Of Beneficiaries Age 65 to 74 | 352 |
| Number Of Beneficiaries Age 75 to 84 | 351 |
| Number Of Beneficiaries Age Greater 84 | 252 |
| Number Of Female Beneficiaries | 788 |
| Number Of Male Beneficiaries | 468 |
| Number Of Non Hispanic White Beneficiaries | 1112 |
| Number Of Black or African American Beneficiaries | 75 |
| Number Of AsianPacific Islander Beneficiaries | 22 |
| Number Of Hispanic Beneficiaries | 26 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 930 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 326 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 23 |
| Percent Of With Chronic Kidney Disease | 33 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 45 |
| Percent Of With Hypertension | 63 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | 15 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.6131 |