| National Provider Identifier [NPI]: | 1952418063 |
| Last Name Of The Provider | THEOBALD |
| First Name Of The Provider | RICHARD |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 601 REED AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MANITOWOC |
| Zip Code Of The Provider | 542211270 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 81 |
| Number Of Services | 6020 |
| Number Of Medicare Beneficiaries | 652 |
| Total Submitted Charge Amount | 810025.19 |
| Total Medicare Allowed Amount | 213375.4 |
| Total Medicare Payment Amount | 165025.13 |
| Total Medicare Standardized Payment Amount | 171643.61 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 271 |
| Number Of Medicare Beneficiaries With Drug Services | 194 |
| Total Drug Submitted ChargeAmount | 13855.19 |
| Total Drug Medicare AllowedAmount | 7007.5 |
| Total Drug Medicare PaymentAmount | 6710.55 |
| Total Drug Medicare Standardized Payment Amount | 6710.55 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 71 |
| Number Of Medical Services | 5749 |
| Number Of Medicare Beneficiaries With Medical Services | 652 |
| Total Medical Submitted Charge Amount | 796170 |
| Total Medical Medicare Allowed Amount | 206367.9 |
| Total Medical Medicare Payment Amount | 158314.58 |
| Total Medical Medicare Standardized Payment Amount | 164933.06 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 79 |
| Number Of Beneficiaries Age 65 to 74 | 212 |
| Number Of Beneficiaries Age 75 to 84 | 198 |
| Number Of Beneficiaries Age Greater 84 | 163 |
| Number Of Female Beneficiaries | 340 |
| Number Of Male Beneficiaries | 312 |
| Number Of Non Hispanic White Beneficiaries | 629 |
| 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 | 527 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 125 |
| Percent Of With Atrial Fibrillation | 18 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 23 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 66 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.228 |