| National Provider Identifier [NPI]: | 1487664454 |
| Last Name Of The Provider | VIDAL |
| First Name Of The Provider | JORGE |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 267 SIERRA MORENA PMB 283 |
| Street Address 2 Of The Provider | URB LAS CUMBRES |
| City Of The Provider | SAN JUAN |
| Zip Code Of The Provider | 009265636 |
| State Code Of The Provider | PR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 80 |
| Number Of Services | 1056 |
| Number Of Medicare Beneficiaries | 472 |
| Total Submitted Charge Amount | 54828.15 |
| Total Medicare Allowed Amount | 53006.09 |
| Total Medicare Payment Amount | 37820.56 |
| Total Medicare Standardized Payment Amount | 50812.1 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 355 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 474.6 |
| Total Drug Medicare AllowedAmount | 429.73 |
| Total Drug Medicare PaymentAmount | 314.33 |
| Total Drug Medicare Standardized Payment Amount | 314.33 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 78 |
| Number Of Medical Services | 701 |
| Number Of Medicare Beneficiaries With Medical Services | 469 |
| Total Medical Submitted Charge Amount | 54353.55 |
| Total Medical Medicare Allowed Amount | 52576.36 |
| Total Medical Medicare Payment Amount | 37506.23 |
| Total Medical Medicare Standardized Payment Amount | 50497.77 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 88 |
| Number Of Beneficiaries Age 65 to 74 | 173 |
| Number Of Beneficiaries Age 75 to 84 | 171 |
| Number Of Beneficiaries Age Greater 84 | 40 |
| Number Of Female Beneficiaries | 290 |
| Number Of Male Beneficiaries | 182 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 449 |
| Number Of American Indian Alaska Native Beneficiaries | |
| 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 | 5 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 21 |
| Percent Of With Chronic Kidney Disease | 27 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 13 |
| Percent Of With Diabetes | 63 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 41 |
| Percent Of With Osteoporosis | 18 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 53 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.3722 |