| National Provider Identifier [NPI]: | 1497736011 |
| Last Name Of The Provider | SELF |
| First Name Of The Provider | MAXWELL |
| 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 | 403 WOODLAND HILLS BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT SCOTT |
| Zip Code Of The Provider | 667018798 |
| State Code Of The Provider | KS |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 128 |
| Number Of Services | 9744 |
| Number Of Medicare Beneficiaries | 637 |
| Total Submitted Charge Amount | 500670.8 |
| Total Medicare Allowed Amount | 287496.13 |
| Total Medicare Payment Amount | 204971.64 |
| Total Medicare Standardized Payment Amount | 214257.72 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 49 |
| Number Of Drug Services | 6856 |
| Number Of Medicare Beneficiaries With Drug Services | 225 |
| Total Drug Submitted ChargeAmount | 218792.8 |
| Total Drug Medicare AllowedAmount | 95924.3 |
| Total Drug Medicare PaymentAmount | 75464.04 |
| Total Drug Medicare Standardized Payment Amount | 75464.04 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 79 |
| Number Of Medical Services | 2888 |
| Number Of Medicare Beneficiaries With Medical Services | 637 |
| Total Medical Submitted Charge Amount | 281878 |
| Total Medical Medicare Allowed Amount | 191571.83 |
| Total Medical Medicare Payment Amount | 129507.6 |
| Total Medical Medicare Standardized Payment Amount | 138793.68 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 126 |
| Number Of Beneficiaries Age 65 to 74 | 217 |
| Number Of Beneficiaries Age 75 to 84 | 167 |
| Number Of Beneficiaries Age Greater 84 | 127 |
| Number Of Female Beneficiaries | 367 |
| Number Of Male Beneficiaries | 270 |
| Number Of Non Hispanic White Beneficiaries | 617 |
| 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 | 462 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 175 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 18 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 63 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.1806 |