| National Provider Identifier [NPI]: | 1548495336 |
| Last Name Of The Provider | CLARK |
| First Name Of The Provider | SHANE |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 5300 FAR HILLS AVENUE |
| Street Address 2 Of The Provider | |
| City Of The Provider | DAYTON |
| Zip Code Of The Provider | 454292347 |
| State Code Of The Provider | OH |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Dermatology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 63 |
| Number Of Services | 2779 |
| Number Of Medicare Beneficiaries | 473 |
| Total Submitted Charge Amount | 274903.5 |
| Total Medicare Allowed Amount | 152707.91 |
| Total Medicare Payment Amount | 112388.7 |
| Total Medicare Standardized Payment Amount | 117014.12 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 101 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 505 |
| Total Drug Medicare AllowedAmount | 178.9 |
| Total Drug Medicare PaymentAmount | 131.88 |
| Total Drug Medicare Standardized Payment Amount | 131.88 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 62 |
| Number Of Medical Services | 2678 |
| Number Of Medicare Beneficiaries With Medical Services | 473 |
| Total Medical Submitted Charge Amount | 274398.5 |
| Total Medical Medicare Allowed Amount | 152529.01 |
| Total Medical Medicare Payment Amount | 112256.82 |
| Total Medical Medicare Standardized Payment Amount | 116882.24 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 31 |
| Number Of Beneficiaries Age 65 to 74 | 210 |
| Number Of Beneficiaries Age 75 to 84 | 177 |
| Number Of Beneficiaries Age Greater 84 | 55 |
| Number Of Female Beneficiaries | 261 |
| Number Of Male Beneficiaries | 212 |
| Number Of Non Hispanic White Beneficiaries | 458 |
| 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 | 425 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 48 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 5 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 12 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.013 |