| National Provider Identifier [NPI]: | 1972762821 |
| Last Name Of The Provider | ETHERIDGE |
| First Name Of The Provider | LATOYA |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 178 SAVIN ST STE 100 |
| Street Address 2 Of The Provider | HALLMARK HEALTH MEDICAL ASSOCIATES INC. |
| City Of The Provider | MALDEN |
| Zip Code Of The Provider | 021483591 |
| State Code Of The Provider | MA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 40 |
| Number Of Services | 662 |
| Number Of Medicare Beneficiaries | 190 |
| Total Submitted Charge Amount | 146533 |
| Total Medicare Allowed Amount | 50051.13 |
| Total Medicare Payment Amount | 36200.15 |
| Total Medicare Standardized Payment Amount | 34154.2 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 37 |
| Number Of Medicare Beneficiaries With Drug Services | 35 |
| Total Drug Submitted ChargeAmount | 1948 |
| Total Drug Medicare AllowedAmount | 1132.55 |
| Total Drug Medicare PaymentAmount | 1090.29 |
| Total Drug Medicare Standardized Payment Amount | 1090.29 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 625 |
| Number Of Medicare Beneficiaries With Medical Services | 190 |
| Total Medical Submitted Charge Amount | 144585 |
| Total Medical Medicare Allowed Amount | 48918.58 |
| Total Medical Medicare Payment Amount | 35109.86 |
| Total Medical Medicare Standardized Payment Amount | 33063.91 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 64 |
| Number Of Beneficiaries Age 65 to 74 | 76 |
| Number Of Beneficiaries Age 75 to 84 | 32 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 138 |
| Number Of Male Beneficiaries | 52 |
| Number Of Non Hispanic White Beneficiaries | 167 |
| 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 | 95 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 95 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 30 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 44 |
| Percent Of With Hypertension | 51 |
| Percent Of With Ischemic Heart Disease | 22 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2236 |