| National Provider Identifier [NPI]: | 1124002712 |
| Last Name Of The Provider | WALL |
| First Name Of The Provider | CAROLYN |
| Middle Initial Of The Provider | K |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 203 INDIGO DRIVE |
| Street Address 2 Of The Provider | SOUTHEASTERN PATHOLOGY ASSOCIATES, PC |
| City Of The Provider | BRUNSWICK |
| Zip Code Of The Provider | 31525 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pathology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 19 |
| Number Of Services | 544 |
| Number Of Medicare Beneficiaries | 179 |
| Total Submitted Charge Amount | 100957.66 |
| Total Medicare Allowed Amount | 27301.53 |
| Total Medicare Payment Amount | 21084.39 |
| Total Medicare Standardized Payment Amount | 16446.61 |
| 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 | 19 |
| Number Of Medical Services | 544 |
| Number Of Medicare Beneficiaries With Medical Services | 179 |
| Total Medical Submitted Charge Amount | 100957.66 |
| Total Medical Medicare Allowed Amount | 27301.53 |
| Total Medical Medicare Payment Amount | 21084.39 |
| Total Medical Medicare Standardized Payment Amount | 16446.61 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 25 |
| Number Of Beneficiaries Age 65 to 74 | 79 |
| Number Of Beneficiaries Age 75 to 84 | 59 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 97 |
| Number Of Male Beneficiaries | 82 |
| Number Of Non Hispanic White Beneficiaries | 167 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 142 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 37 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 30 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 23 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.0726 |