| National Provider Identifier [NPI]: | 1942402169 |
| Last Name Of The Provider | KELLER |
| First Name Of The Provider | WADE |
| 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 | 6051 N EAGLE RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | BOISE |
| Zip Code Of The Provider | 837130997 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Dermatology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 50 |
| Number Of Services | 1471 |
| Number Of Medicare Beneficiaries | 324 |
| Total Submitted Charge Amount | 250062 |
| Total Medicare Allowed Amount | 110863.35 |
| Total Medicare Payment Amount | 81388.15 |
| Total Medicare Standardized Payment Amount | 86562.9 |
| 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 | 75 |
| Number Of Beneficiaries Age Less65 | 16 |
| Number Of Beneficiaries Age 65 to 74 | 156 |
| Number Of Beneficiaries Age 75 to 84 | 105 |
| Number Of Beneficiaries Age Greater 84 | 47 |
| Number Of Female Beneficiaries | 158 |
| Number Of Male Beneficiaries | 166 |
| Number Of Non Hispanic White Beneficiaries | 313 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 6 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 19 |
| Percent Of With Hyperlipidemia | 43 |
| Percent Of With Hypertension | 47 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8417 |