| National Provider Identifier [NPI]: | 1790890341 |
| Last Name Of The Provider | FULLER |
| First Name Of The Provider | CLARK |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 8635 W 3RD ST |
| Street Address 2 Of The Provider | SUITE 975W |
| City Of The Provider | LOS ANGELES |
| Zip Code Of The Provider | 900486101 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Thoracic Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 60 |
| Number Of Services | 544 |
| Number Of Medicare Beneficiaries | 207 |
| Total Submitted Charge Amount | 1215856 |
| Total Medicare Allowed Amount | 172244.66 |
| Total Medicare Payment Amount | 134790.63 |
| Total Medicare Standardized Payment Amount | 129465.76 |
| 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 | 60 |
| Number Of Medical Services | 544 |
| Number Of Medicare Beneficiaries With Medical Services | 207 |
| Total Medical Submitted Charge Amount | 1215856 |
| Total Medical Medicare Allowed Amount | 172244.66 |
| Total Medical Medicare Payment Amount | 134790.63 |
| Total Medical Medicare Standardized Payment Amount | 129465.76 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 15 |
| Number Of Beneficiaries Age 65 to 74 | 80 |
| Number Of Beneficiaries Age 75 to 84 | 72 |
| Number Of Beneficiaries Age Greater 84 | 40 |
| Number Of Female Beneficiaries | 111 |
| Number Of Male Beneficiaries | 96 |
| Number Of Non Hispanic White Beneficiaries | 158 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 17 |
| Number Of Hispanic Beneficiaries | 14 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 159 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 48 |
| Percent Of With Atrial Fibrillation | 18 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 17 |
| Percent Of With Cancer | 63 |
| Percent Of With Heart Failure | 27 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 38 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 54 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 43 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.8414 |