| National Provider Identifier [NPI]: | 1528148889 |
| Last Name Of The Provider | BOULLIOUN |
| First Name Of The Provider | SUSAN |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 113 E CEDAR ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | SEGUIN |
| Zip Code Of The Provider | 78155 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 53 |
| Number Of Services | 1925 |
| Number Of Medicare Beneficiaries | 414 |
| Total Submitted Charge Amount | 179335 |
| Total Medicare Allowed Amount | 114377.19 |
| Total Medicare Payment Amount | 79834.55 |
| Total Medicare Standardized Payment Amount | 85474.51 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 184 |
| Number Of Medicare Beneficiaries With Drug Services | 115 |
| Total Drug Submitted ChargeAmount | 5230 |
| Total Drug Medicare AllowedAmount | 1934.9 |
| Total Drug Medicare PaymentAmount | 1657.54 |
| Total Drug Medicare Standardized Payment Amount | 1657.54 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 45 |
| Number Of Medical Services | 1741 |
| Number Of Medicare Beneficiaries With Medical Services | 414 |
| Total Medical Submitted Charge Amount | 174105 |
| Total Medical Medicare Allowed Amount | 112442.29 |
| Total Medical Medicare Payment Amount | 78177.01 |
| Total Medical Medicare Standardized Payment Amount | 83816.97 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 149 |
| Number Of Beneficiaries Age 65 to 74 | 134 |
| Number Of Beneficiaries Age 75 to 84 | 82 |
| Number Of Beneficiaries Age Greater 84 | 49 |
| Number Of Female Beneficiaries | 304 |
| Number Of Male Beneficiaries | 110 |
| Number Of Non Hispanic White Beneficiaries | 280 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 111 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 257 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 157 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 25 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 43 |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.4094 |