| National Provider Identifier [NPI]: | 1629069059 |
| Last Name Of The Provider | MAMANTOV |
| First Name Of The Provider | TATIANA |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 20103 LAKE CHABOT RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | CASTRO VALLEY |
| Zip Code Of The Provider | 945465341 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 33 |
| Number Of Services | 541 |
| Number Of Medicare Beneficiaries | 377 |
| Total Submitted Charge Amount | 296707 |
| Total Medicare Allowed Amount | 67553.25 |
| Total Medicare Payment Amount | 52347.42 |
| Total Medicare Standardized Payment Amount | 49377.24 |
| Drug Suppress Indicator | * |
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| Number Of Medicare Beneficiaries With Drug Services | |
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| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
| Number Of Medical Services | |
| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
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| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 98 |
| Number Of Beneficiaries Age 65 to 74 | 104 |
| Number Of Beneficiaries Age 75 to 84 | 85 |
| Number Of Beneficiaries Age Greater 84 | 90 |
| Number Of Female Beneficiaries | 214 |
| Number Of Male Beneficiaries | 163 |
| Number Of Non Hispanic White Beneficiaries | 212 |
| Number Of Black or African American Beneficiaries | 67 |
| Number Of AsianPacific Islander Beneficiaries | 26 |
| Number Of Hispanic Beneficiaries | 60 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 192 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 185 |
| Percent Of With Atrial Fibrillation | 16 |
| Percent Of With Alzheimers Disease or Dementia | 27 |
| Percent Of With Asthma | 15 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 35 |
| Percent Of With Chronic Kidney Disease | 45 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 28 |
| Percent Of With Depression | 35 |
| Percent Of With Diabetes | 42 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 15 |
| Percent Of With Stroke | 15 |
| Average HCC Risk Score Of Beneficiaries | 2.1455 |