| National Provider Identifier [NPI]: | 1407815558 |
| Last Name Of The Provider | DOMBECK |
| First Name Of The Provider | TEAGUE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 201 E NICOLLET BLVD |
| Street Address 2 Of The Provider | FAIRVIEW RIDGES HOSPITAL |
| City Of The Provider | BURNSVILLE |
| Zip Code Of The Provider | 553375714 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 54 |
| Number Of Services | 1152 |
| Number Of Medicare Beneficiaries | 466 |
| Total Submitted Charge Amount | 300316.07 |
| Total Medicare Allowed Amount | 66390.85 |
| Total Medicare Payment Amount | 50891.2 |
| Total Medicare Standardized Payment Amount | 52728.92 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 446 |
| Number Of Medicare Beneficiaries With Drug Services | 19 |
| Total Drug Submitted ChargeAmount | 1142.03 |
| Total Drug Medicare AllowedAmount | 114.27 |
| Total Drug Medicare PaymentAmount | 89.59 |
| Total Drug Medicare Standardized Payment Amount | 89.59 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 44 |
| Number Of Medical Services | 706 |
| Number Of Medicare Beneficiaries With Medical Services | 465 |
| Total Medical Submitted Charge Amount | 299174.04 |
| Total Medical Medicare Allowed Amount | 66276.58 |
| Total Medical Medicare Payment Amount | 50801.61 |
| Total Medical Medicare Standardized Payment Amount | 52639.33 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 162 |
| Number Of Beneficiaries Age 65 to 74 | 103 |
| Number Of Beneficiaries Age 75 to 84 | 113 |
| Number Of Beneficiaries Age Greater 84 | 88 |
| Number Of Female Beneficiaries | 252 |
| Number Of Male Beneficiaries | 214 |
| Number Of Non Hispanic White Beneficiaries | 436 |
| Number Of Black or African American Beneficiaries | 11 |
| 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 | 287 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 179 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 15 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 28 |
| Percent Of With Chronic Kidney Disease | 37 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 41 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 17 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.6447 |