| National Provider Identifier [NPI]: | 1497713200 |
| Last Name Of The Provider | SAMPLE |
| First Name Of The Provider | RICHARD |
| 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 | 4371 NARROW LANE RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | MONTGOMERY |
| Zip Code Of The Provider | 361162971 |
| State Code Of The Provider | AL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 27 |
| Number Of Services | 2309 |
| Number Of Medicare Beneficiaries | 1268 |
| Total Submitted Charge Amount | 1867042 |
| Total Medicare Allowed Amount | 265388.87 |
| Total Medicare Payment Amount | 204211.74 |
| Total Medicare Standardized Payment Amount | 216326.61 |
| 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 | 27 |
| Number Of Medical Services | 2309 |
| Number Of Medicare Beneficiaries With Medical Services | 1268 |
| Total Medical Submitted Charge Amount | 1867042 |
| Total Medical Medicare Allowed Amount | 265388.87 |
| Total Medical Medicare Payment Amount | 204211.74 |
| Total Medical Medicare Standardized Payment Amount | 216326.61 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 319 |
| Number Of Beneficiaries Age 65 to 74 | 353 |
| Number Of Beneficiaries Age 75 to 84 | 312 |
| Number Of Beneficiaries Age Greater 84 | 284 |
| Number Of Female Beneficiaries | 719 |
| Number Of Male Beneficiaries | 549 |
| Number Of Non Hispanic White Beneficiaries | 708 |
| Number Of Black or African American Beneficiaries | 543 |
| 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 | 812 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 456 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 30 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 44 |
| Percent Of With Chronic Kidney Disease | 47 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 31 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 50 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 55 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | 16 |
| Average HCC Risk Score Of Beneficiaries | 2.2246 |