| National Provider Identifier [NPI]: | 1902983075 |
| Last Name Of The Provider | HAVERSTICK |
| First Name Of The Provider | DALE |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | HIGHWAY 19 SOUTH |
| Street Address 2 Of The Provider | |
| City Of The Provider | EMINENCE |
| Zip Code Of The Provider | 65466 |
| State Code Of The Provider | MO |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 1826 |
| Number Of Medicare Beneficiaries | 194 |
| Total Submitted Charge Amount | 113742 |
| Total Medicare Allowed Amount | 73612.42 |
| Total Medicare Payment Amount | 51617.88 |
| Total Medicare Standardized Payment Amount | 56973.63 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 988 |
| Number Of Medicare Beneficiaries With Drug Services | 110 |
| Total Drug Submitted ChargeAmount | 19397 |
| Total Drug Medicare AllowedAmount | 11108.05 |
| Total Drug Medicare PaymentAmount | 8990.96 |
| Total Drug Medicare Standardized Payment Amount | 8990.96 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 33 |
| Number Of Medical Services | 838 |
| Number Of Medicare Beneficiaries With Medical Services | 194 |
| Total Medical Submitted Charge Amount | 94345 |
| Total Medical Medicare Allowed Amount | 62504.37 |
| Total Medical Medicare Payment Amount | 42626.92 |
| Total Medical Medicare Standardized Payment Amount | 47982.67 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 27 |
| Number Of Beneficiaries Age 65 to 74 | 105 |
| Number Of Beneficiaries Age 75 to 84 | 51 |
| Number Of Beneficiaries Age Greater 84 | 11 |
| Number Of Female Beneficiaries | 96 |
| Number Of Male Beneficiaries | 98 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 176 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 18 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 24 |
| Percent Of With Diabetes | 22 |
| Percent Of With Hyperlipidemia | 45 |
| Percent Of With Hypertension | 54 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9076 |