| National Provider Identifier [NPI]: | 1851471072 |
| Last Name Of The Provider | WIDICUS |
| First Name Of The Provider | DIANA |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1836 SOUTH MACARTHUR BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | SPRINGFIELD |
| Zip Code Of The Provider | 62704 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 117 |
| Number Of Services | 3468 |
| Number Of Medicare Beneficiaries | 271 |
| Total Submitted Charge Amount | 210504 |
| Total Medicare Allowed Amount | 88422.83 |
| Total Medicare Payment Amount | 66783.97 |
| Total Medicare Standardized Payment Amount | 69692.09 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 18 |
| Number Of Drug Services | 812 |
| Number Of Medicare Beneficiaries With Drug Services | 88 |
| Total Drug Submitted ChargeAmount | 34113 |
| Total Drug Medicare AllowedAmount | 10063.74 |
| Total Drug Medicare PaymentAmount | 7924.03 |
| Total Drug Medicare Standardized Payment Amount | 7924.03 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 99 |
| Number Of Medical Services | 2656 |
| Number Of Medicare Beneficiaries With Medical Services | 271 |
| Total Medical Submitted Charge Amount | 176391 |
| Total Medical Medicare Allowed Amount | 78359.09 |
| Total Medical Medicare Payment Amount | 58859.94 |
| Total Medical Medicare Standardized Payment Amount | 61768.06 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 34 |
| Number Of Beneficiaries Age 65 to 74 | 159 |
| Number Of Beneficiaries Age 75 to 84 | 61 |
| Number Of Beneficiaries Age Greater 84 | 17 |
| Number Of Female Beneficiaries | 207 |
| Number Of Male Beneficiaries | 64 |
| Number Of Non Hispanic White Beneficiaries | 254 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 242 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 29 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 39 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 20 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8603 |