| National Provider Identifier [NPI]: | 1194999409 |
| Last Name Of The Provider | GUSTAFSON |
| First Name Of The Provider | KELLY |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | PSYD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 938 HEMLOCK ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | DEERFIELD |
| Zip Code Of The Provider | 60015 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Clinical Psychologist |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 6 |
| Number Of Services | 939 |
| Number Of Medicare Beneficiaries | 164 |
| Total Submitted Charge Amount | 102660 |
| Total Medicare Allowed Amount | 85325.59 |
| Total Medicare Payment Amount | 66842.74 |
| Total Medicare Standardized Payment Amount | 59268.53 |
| 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 | 6 |
| Number Of Medical Services | 939 |
| Number Of Medicare Beneficiaries With Medical Services | 164 |
| Total Medical Submitted Charge Amount | 102660 |
| Total Medical Medicare Allowed Amount | 85325.59 |
| Total Medical Medicare Payment Amount | 66842.74 |
| Total Medical Medicare Standardized Payment Amount | 59268.53 |
| Average Age Of Beneficiaries | 81 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | 53 |
| Number Of Beneficiaries Age Greater 84 | 69 |
| Number Of Female Beneficiaries | 112 |
| Number Of Male Beneficiaries | 52 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 85 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 79 |
| Percent Of With Atrial Fibrillation | 27 |
| Percent Of With Alzheimers Disease or Dementia | 66 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 47 |
| Percent Of With Chronic Kidney Disease | 43 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 35 |
| Percent Of With Depression | 75 |
| Percent Of With Diabetes | 40 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 63 |
| Percent Of With Osteoporosis | 18 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 63 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 19 |
| Percent Of With Stroke | 20 |
| Average HCC Risk Score Of Beneficiaries | 2.3189 |