| National Provider Identifier [NPI]: | 1194049049 |
| Last Name Of The Provider | TA |
| First Name Of The Provider | DAT |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 10628 PARK RD |
| Street Address 2 Of The Provider | EMERGENCY DEPARTMENT |
| City Of The Provider | CHARLOTTE |
| Zip Code Of The Provider | 282108407 |
| State Code Of The Provider | NC |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 36 |
| Number Of Services | 908 |
| Number Of Medicare Beneficiaries | 560 |
| Total Submitted Charge Amount | 487684.8 |
| Total Medicare Allowed Amount | 93869.57 |
| Total Medicare Payment Amount | 70556.71 |
| Total Medicare Standardized Payment Amount | 74211.17 |
| 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 | 36 |
| Number Of Medical Services | 908 |
| Number Of Medicare Beneficiaries With Medical Services | 560 |
| Total Medical Submitted Charge Amount | 487684.8 |
| Total Medical Medicare Allowed Amount | 93869.57 |
| Total Medical Medicare Payment Amount | 70556.71 |
| Total Medical Medicare Standardized Payment Amount | 74211.17 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 138 |
| Number Of Beneficiaries Age 65 to 74 | 177 |
| Number Of Beneficiaries Age 75 to 84 | 145 |
| Number Of Beneficiaries Age Greater 84 | 100 |
| Number Of Female Beneficiaries | 356 |
| Number Of Male Beneficiaries | 204 |
| Number Of Non Hispanic White Beneficiaries | 427 |
| Number Of Black or African American Beneficiaries | 105 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 15 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 433 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 127 |
| Percent Of With Atrial Fibrillation | 16 |
| Percent Of With Alzheimers Disease or Dementia | 21 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 34 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.5932 |