| National Provider Identifier [NPI]: | 1821069691 |
| Last Name Of The Provider | FETTEROLF |
| First Name Of The Provider | MICHAEL |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1405 MILL ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | NEW LONDON |
| Zip Code Of The Provider | 549612155 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 128 |
| Number Of Services | 940 |
| Number Of Medicare Beneficiaries | 182 |
| Total Submitted Charge Amount | 80393.95 |
| Total Medicare Allowed Amount | 27928.39 |
| Total Medicare Payment Amount | 22116.44 |
| Total Medicare Standardized Payment Amount | 22944.65 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 30 |
| Number Of Medicare Beneficiaries With Drug Services | 21 |
| Total Drug Submitted ChargeAmount | 762 |
| Total Drug Medicare AllowedAmount | 715.92 |
| Total Drug Medicare PaymentAmount | 698.83 |
| Total Drug Medicare Standardized Payment Amount | 698.83 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 122 |
| Number Of Medical Services | 910 |
| Number Of Medicare Beneficiaries With Medical Services | 182 |
| Total Medical Submitted Charge Amount | 79631.95 |
| Total Medical Medicare Allowed Amount | 27212.47 |
| Total Medical Medicare Payment Amount | 21417.61 |
| Total Medical Medicare Standardized Payment Amount | 22245.82 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 49 |
| Number Of Beneficiaries Age 65 to 74 | 58 |
| Number Of Beneficiaries Age 75 to 84 | 41 |
| Number Of Beneficiaries Age Greater 84 | 34 |
| Number Of Female Beneficiaries | 99 |
| Number Of Male Beneficiaries | 83 |
| 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 | 120 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 62 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 29 |
| Percent Of With Chronic Kidney Disease | 29 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 64 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 35 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.4368 |