| National Provider Identifier [NPI]: | 1003877077 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | MARK |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2055 N MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | TOOELE |
| Zip Code Of The Provider | 840749819 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 38 |
| Number Of Services | 510 |
| Number Of Medicare Beneficiaries | 313 |
| Total Submitted Charge Amount | 299716 |
| Total Medicare Allowed Amount | 53607.87 |
| Total Medicare Payment Amount | 39514.9 |
| Total Medicare Standardized Payment Amount | 40400.28 |
| 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 | 38 |
| Number Of Medical Services | 510 |
| Number Of Medicare Beneficiaries With Medical Services | 313 |
| Total Medical Submitted Charge Amount | 299716 |
| Total Medical Medicare Allowed Amount | 53607.87 |
| Total Medical Medicare Payment Amount | 39514.9 |
| Total Medical Medicare Standardized Payment Amount | 40400.28 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 80 |
| Number Of Beneficiaries Age 65 to 74 | 93 |
| Number Of Beneficiaries Age 75 to 84 | 89 |
| Number Of Beneficiaries Age Greater 84 | 51 |
| Number Of Female Beneficiaries | 174 |
| Number Of Male Beneficiaries | 139 |
| Number Of Non Hispanic White Beneficiaries | 139 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 95 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 172 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 141 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 35 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 47 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.8428 |