| National Provider Identifier [NPI]: | 1831162791 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | THEODORE |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2512 E DUPONT RD |
| Street Address 2 Of The Provider | STE. 100 |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468251675 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Urology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 91 |
| Number Of Services | 5324 |
| Number Of Medicare Beneficiaries | 674 |
| Total Submitted Charge Amount | 518079.69 |
| Total Medicare Allowed Amount | 173517.64 |
| Total Medicare Payment Amount | 129185.7 |
| Total Medicare Standardized Payment Amount | 137720.69 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 2471 |
| Number Of Medicare Beneficiaries With Drug Services | 64 |
| Total Drug Submitted ChargeAmount | 57057.4 |
| Total Drug Medicare AllowedAmount | 11811.79 |
| Total Drug Medicare PaymentAmount | 9106.29 |
| Total Drug Medicare Standardized Payment Amount | 9106.29 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 85 |
| Number Of Medical Services | 2853 |
| Number Of Medicare Beneficiaries With Medical Services | 674 |
| Total Medical Submitted Charge Amount | 461022.29 |
| Total Medical Medicare Allowed Amount | 161705.85 |
| Total Medical Medicare Payment Amount | 120079.41 |
| Total Medical Medicare Standardized Payment Amount | 128614.4 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 77 |
| Number Of Beneficiaries Age 65 to 74 | 322 |
| Number Of Beneficiaries Age 75 to 84 | 193 |
| Number Of Beneficiaries Age Greater 84 | 82 |
| Number Of Female Beneficiaries | 229 |
| Number Of Male Beneficiaries | 445 |
| Number Of Non Hispanic White Beneficiaries | 623 |
| Number Of Black or African American Beneficiaries | 28 |
| 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 | 599 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 75 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 22 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 30 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 56 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.1808 |