| National Provider Identifier [NPI]: | 1780813139 |
| Last Name Of The Provider | WISSINK |
| First Name Of The Provider | THEODORE |
| Middle Initial Of The Provider | F |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2727 W HOLCOMBE BLVD FL 1 |
| Street Address 2 Of The Provider | |
| City Of The Provider | HOUSTON |
| Zip Code Of The Provider | 770251669 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 30 |
| Number Of Services | 272 |
| Number Of Medicare Beneficiaries | 181 |
| Total Submitted Charge Amount | 6762 |
| Total Medicare Allowed Amount | 2754.66 |
| Total Medicare Payment Amount | 2133.92 |
| Total Medicare Standardized Payment Amount | 2143.22 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 30 |
| Number Of Medical Services | 272 |
| Number Of Medicare Beneficiaries With Medical Services | 181 |
| Total Medical Submitted Charge Amount | 6762 |
| Total Medical Medicare Allowed Amount | 2754.66 |
| Total Medical Medicare Payment Amount | 2133.92 |
| Total Medical Medicare Standardized Payment Amount | 2143.22 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 52 |
| Number Of Beneficiaries Age 65 to 74 | 71 |
| Number Of Beneficiaries Age 75 to 84 | 32 |
| Number Of Beneficiaries Age Greater 84 | 26 |
| Number Of Female Beneficiaries | 90 |
| Number Of Male Beneficiaries | 91 |
| Number Of Non Hispanic White Beneficiaries | 159 |
| 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 | 123 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 58 |
| Percent Of With Atrial Fibrillation | 21 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 33 |
| Percent Of With Chronic Kidney Disease | 45 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 49 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 13 |
| Average HCC Risk Score Of Beneficiaries | 1.5224 |