| National Provider Identifier [NPI]: | 1619050424 |
| Last Name Of The Provider | PETERSEN |
| First Name Of The Provider | DAVID |
| 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 | 2315 8TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | LEWISTON |
| Zip Code Of The Provider | 835017301 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 140 |
| Number Of Services | 6687 |
| Number Of Medicare Beneficiaries | 457 |
| Total Submitted Charge Amount | 358391.52 |
| Total Medicare Allowed Amount | 161011.91 |
| Total Medicare Payment Amount | 114599.73 |
| Total Medicare Standardized Payment Amount | 124685.95 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 1365 |
| Number Of Medicare Beneficiaries With Drug Services | 77 |
| Total Drug Submitted ChargeAmount | 2023.46 |
| Total Drug Medicare AllowedAmount | 983.83 |
| Total Drug Medicare PaymentAmount | 736.03 |
| Total Drug Medicare Standardized Payment Amount | 736.03 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 130 |
| Number Of Medical Services | 5322 |
| Number Of Medicare Beneficiaries With Medical Services | 457 |
| Total Medical Submitted Charge Amount | 356368.06 |
| Total Medical Medicare Allowed Amount | 160028.08 |
| Total Medical Medicare Payment Amount | 113863.7 |
| Total Medical Medicare Standardized Payment Amount | 123949.92 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 54 |
| Number Of Beneficiaries Age 65 to 74 | 202 |
| Number Of Beneficiaries Age 75 to 84 | 126 |
| Number Of Beneficiaries Age Greater 84 | 75 |
| Number Of Female Beneficiaries | 213 |
| Number Of Male Beneficiaries | 244 |
| 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 | 396 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 61 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 11 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 25 |
| Percent Of With Hypertension | 50 |
| Percent Of With Ischemic Heart Disease | 21 |
| Percent Of With Osteoporosis | 3 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 25 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.0025 |