| National Provider Identifier [NPI]: | 1841240686 |
| Last Name Of The Provider | DETLIE |
| First Name Of The Provider | TORE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 918 DEMONT AVE E |
| Street Address 2 Of The Provider | |
| City Of The Provider | MAPLEWOOD |
| Zip Code Of The Provider | 551091953 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 112 |
| Number Of Services | 2283 |
| Number Of Medicare Beneficiaries | 1075 |
| Total Submitted Charge Amount | 234459 |
| Total Medicare Allowed Amount | 66707.97 |
| Total Medicare Payment Amount | 55789.55 |
| Total Medicare Standardized Payment Amount | 56777.13 |
| Drug Suppress Indicator | * |
| Number Of HCPCS Associated With Drug Services | |
| Number Of Drug Services | |
| Number Of Medicare Beneficiaries With Drug Services | |
| Total Drug Submitted ChargeAmount | |
| Total Drug Medicare AllowedAmount | |
| Total Drug Medicare PaymentAmount | |
| Total Drug Medicare Standardized Payment Amount | |
| 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 | |
| Total Medical Medicare Payment Amount | |
| Total Medical Medicare Standardized Payment Amount | |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 263 |
| Number Of Beneficiaries Age 65 to 74 | 412 |
| Number Of Beneficiaries Age 75 to 84 | 283 |
| Number Of Beneficiaries Age Greater 84 | 117 |
| Number Of Female Beneficiaries | 796 |
| Number Of Male Beneficiaries | 279 |
| Number Of Non Hispanic White Beneficiaries | 848 |
| Number Of Black or African American Beneficiaries | 103 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 93 |
| Number Of American Indian Alaska Native Beneficiaries | 15 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 734 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 341 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 17 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 27 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 51 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 10 |
| Percent Of With Stroke | 9 |
| Average HCC Risk Score Of Beneficiaries | 1.6276 |