| National Provider Identifier [NPI]: | 1275725384 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | TIMOTHY |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 855 N WESTHAVEN DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | OSHKOSH |
| Zip Code Of The Provider | 549047668 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 32 |
| Number Of Services | 428 |
| Number Of Medicare Beneficiaries | 154 |
| Total Submitted Charge Amount | 98019.66 |
| Total Medicare Allowed Amount | 33472.3 |
| Total Medicare Payment Amount | 24425.09 |
| Total Medicare Standardized Payment Amount | 26133.26 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 33 |
| Number Of Medicare Beneficiaries With Drug Services | 29 |
| Total Drug Submitted ChargeAmount | 1420.66 |
| Total Drug Medicare AllowedAmount | 807.45 |
| Total Drug Medicare PaymentAmount | 691.85 |
| Total Drug Medicare Standardized Payment Amount | 691.85 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 26 |
| Number Of Medical Services | 395 |
| Number Of Medicare Beneficiaries With Medical Services | 153 |
| Total Medical Submitted Charge Amount | 96599 |
| Total Medical Medicare Allowed Amount | 32664.85 |
| Total Medical Medicare Payment Amount | 23733.24 |
| Total Medical Medicare Standardized Payment Amount | 25441.41 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 55 |
| Number Of Beneficiaries Age 65 to 74 | 51 |
| Number Of Beneficiaries Age 75 to 84 | 33 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 87 |
| Number Of Male Beneficiaries | 67 |
| Number Of Non Hispanic White Beneficiaries | 142 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 95 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 59 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 12 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2705 |