| National Provider Identifier [NPI]: | 1811964174 |
| Last Name Of The Provider | JOHNSON |
| First Name Of The Provider | BLAKE |
| 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 | 5775 WAYZATA BLVD |
| Street Address 2 Of The Provider | STE 190 |
| City Of The Provider | ST LOUIS PARK |
| Zip Code Of The Provider | 55416 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 137 |
| Number Of Services | 6396 |
| Number Of Medicare Beneficiaries | 764 |
| Total Submitted Charge Amount | 1228587.35 |
| Total Medicare Allowed Amount | 166302.61 |
| Total Medicare Payment Amount | 126233.11 |
| Total Medicare Standardized Payment Amount | 125775.72 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 15 |
| Number Of Drug Services | 5154 |
| Number Of Medicare Beneficiaries With Drug Services | 242 |
| Total Drug Submitted ChargeAmount | 59476 |
| Total Drug Medicare AllowedAmount | 2983.32 |
| Total Drug Medicare PaymentAmount | 2335.21 |
| Total Drug Medicare Standardized Payment Amount | 2335.21 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 122 |
| Number Of Medical Services | 1242 |
| Number Of Medicare Beneficiaries With Medical Services | 763 |
| Total Medical Submitted Charge Amount | 1169111.35 |
| Total Medical Medicare Allowed Amount | 163319.29 |
| Total Medical Medicare Payment Amount | 123897.9 |
| Total Medical Medicare Standardized Payment Amount | 123440.51 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 195 |
| Number Of Beneficiaries Age 65 to 74 | 269 |
| Number Of Beneficiaries Age 75 to 84 | 218 |
| Number Of Beneficiaries Age Greater 84 | 82 |
| Number Of Female Beneficiaries | 503 |
| Number Of Male Beneficiaries | 261 |
| Number Of Non Hispanic White Beneficiaries | 700 |
| Number Of Black or African American Beneficiaries | 23 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 11 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 16 |
| Number Of Beneficiaries With Medicare Only Entitlement | 588 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 176 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 58 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 57 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.0681 |