| National Provider Identifier [NPI]: | 1205817871 |
| Last Name Of The Provider | GUSTAFSON |
| First Name Of The Provider | DAVID |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3507 SHADY BEND DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | INDEPENDENCE |
| Zip Code Of The Provider | 640522860 |
| State Code Of The Provider | MO |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 36 |
| Number Of Services | 339 |
| Number Of Medicare Beneficiaries | 167 |
| Total Submitted Charge Amount | 32432.44 |
| Total Medicare Allowed Amount | 22901.24 |
| Total Medicare Payment Amount | 16144.9 |
| Total Medicare Standardized Payment Amount | 17044.74 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 84 |
| Number Of Medicare Beneficiaries With Drug Services | 15 |
| Total Drug Submitted ChargeAmount | 638.44 |
| Total Drug Medicare AllowedAmount | 61.82 |
| Total Drug Medicare PaymentAmount | 48.42 |
| Total Drug Medicare Standardized Payment Amount | 48.42 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 26 |
| Number Of Medical Services | 255 |
| Number Of Medicare Beneficiaries With Medical Services | 167 |
| Total Medical Submitted Charge Amount | 31794 |
| Total Medical Medicare Allowed Amount | 22839.42 |
| Total Medical Medicare Payment Amount | 16096.48 |
| Total Medical Medicare Standardized Payment Amount | 16996.32 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 21 |
| Number Of Beneficiaries Age 65 to 74 | 91 |
| Number Of Beneficiaries Age 75 to 84 | 38 |
| Number Of Beneficiaries Age Greater 84 | 17 |
| Number Of Female Beneficiaries | 117 |
| Number Of Male Beneficiaries | 50 |
| 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 | 154 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 13 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 12 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 20 |
| Percent Of With Hyperlipidemia | 44 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.895 |