| National Provider Identifier [NPI]: | 1619945524 |
| Last Name Of The Provider | VONGSA |
| First Name Of The Provider | SOURASACK |
| Middle Initial Of The Provider | K |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3329 N RICHMOND ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | APPLETON |
| Zip Code Of The Provider | 549111063 |
| 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 | 33 |
| Number Of Services | 493 |
| Number Of Medicare Beneficiaries | 263 |
| Total Submitted Charge Amount | 81263 |
| Total Medicare Allowed Amount | 31811.21 |
| Total Medicare Payment Amount | 21025.05 |
| Total Medicare Standardized Payment Amount | 22346.84 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 55 |
| Number Of Medicare Beneficiaries With Drug Services | 16 |
| Total Drug Submitted ChargeAmount | 558 |
| Total Drug Medicare AllowedAmount | 68.45 |
| Total Drug Medicare PaymentAmount | 50.05 |
| Total Drug Medicare Standardized Payment Amount | 50.05 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 27 |
| Number Of Medical Services | 438 |
| Number Of Medicare Beneficiaries With Medical Services | 263 |
| Total Medical Submitted Charge Amount | 80705 |
| Total Medical Medicare Allowed Amount | 31742.76 |
| Total Medical Medicare Payment Amount | 20975 |
| Total Medical Medicare Standardized Payment Amount | 22296.79 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 82 |
| Number Of Beneficiaries Age 65 to 74 | 84 |
| Number Of Beneficiaries Age 75 to 84 | 67 |
| Number Of Beneficiaries Age Greater 84 | 30 |
| Number Of Female Beneficiaries | 155 |
| Number Of Male Beneficiaries | 108 |
| Number Of Non Hispanic White Beneficiaries | 242 |
| 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 | 159 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 104 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 15 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 31 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.074 |