| National Provider Identifier [NPI]: | 1487883740 |
| Last Name Of The Provider | HARTOJO |
| First Name Of The Provider | WIBISONO |
| 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 | 777 HEMLOCK ST |
| Street Address 2 Of The Provider | MSC #69 |
| City Of The Provider | MACON |
| Zip Code Of The Provider | 312012102 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 12 |
| Number Of Services | 962 |
| Number Of Medicare Beneficiaries | 801 |
| Total Submitted Charge Amount | 452544 |
| Total Medicare Allowed Amount | 178742.6 |
| Total Medicare Payment Amount | 130442.11 |
| Total Medicare Standardized Payment Amount | 135631.72 |
| 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 | 12 |
| Number Of Medical Services | 962 |
| Number Of Medicare Beneficiaries With Medical Services | 801 |
| Total Medical Submitted Charge Amount | 452544 |
| Total Medical Medicare Allowed Amount | 178742.6 |
| Total Medical Medicare Payment Amount | 130442.11 |
| Total Medical Medicare Standardized Payment Amount | 135631.72 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 98 |
| Number Of Beneficiaries Age 65 to 74 | 232 |
| Number Of Beneficiaries Age 75 to 84 | 256 |
| Number Of Beneficiaries Age Greater 84 | 215 |
| Number Of Female Beneficiaries | 477 |
| Number Of Male Beneficiaries | 324 |
| Number Of Non Hispanic White Beneficiaries | 640 |
| Number Of Black or African American Beneficiaries | 76 |
| Number Of AsianPacific Islander Beneficiaries | 45 |
| Number Of Hispanic Beneficiaries | 28 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 12 |
| Number Of Beneficiaries With Medicare Only Entitlement | 670 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 131 |
| Percent Of With Atrial Fibrillation | 26 |
| Percent Of With Alzheimers Disease or Dementia | 28 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 32 |
| Percent Of With Chronic Kidney Disease | 50 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 39 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 54 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 49 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 16 |
| Average HCC Risk Score Of Beneficiaries | 1.7349 |