| National Provider Identifier [NPI]: | 1457307613 |
| Last Name Of The Provider | FORTENBERRY |
| First Name Of The Provider | PHILLIP |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | M.D |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 311 CAMDEN ST |
| Street Address 2 Of The Provider | SUITE 208 |
| City Of The Provider | SAN ANTONIO |
| Zip Code Of The Provider | 782152012 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 162 |
| Number Of Services | 5025 |
| Number Of Medicare Beneficiaries | 1057 |
| Total Submitted Charge Amount | 568436.66 |
| Total Medicare Allowed Amount | 150374.26 |
| Total Medicare Payment Amount | 114724.06 |
| Total Medicare Standardized Payment Amount | 123055.9 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 3498 |
| Number Of Medicare Beneficiaries With Drug Services | 47 |
| Total Drug Submitted ChargeAmount | 4327.02 |
| Total Drug Medicare AllowedAmount | 1102.95 |
| Total Drug Medicare PaymentAmount | 808.54 |
| Total Drug Medicare Standardized Payment Amount | 808.54 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 159 |
| Number Of Medical Services | 1527 |
| Number Of Medicare Beneficiaries With Medical Services | 1057 |
| Total Medical Submitted Charge Amount | 564109.64 |
| Total Medical Medicare Allowed Amount | 149271.31 |
| Total Medical Medicare Payment Amount | 113915.52 |
| Total Medical Medicare Standardized Payment Amount | 122247.36 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 253 |
| Number Of Beneficiaries Age 65 to 74 | 413 |
| Number Of Beneficiaries Age 75 to 84 | 266 |
| Number Of Beneficiaries Age Greater 84 | 125 |
| Number Of Female Beneficiaries | 623 |
| Number Of Male Beneficiaries | 434 |
| Number Of Non Hispanic White Beneficiaries | 485 |
| Number Of Black or African American Beneficiaries | 112 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 443 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 702 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 355 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 19 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 36 |
| Percent Of With Chronic Kidney Disease | 46 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 53 |
| Percent Of With Hyperlipidemia | 66 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 52 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 11 |
| Average HCC Risk Score Of Beneficiaries | 2.3651 |