| National Provider Identifier [NPI]: | 1013025097 |
| Last Name Of The Provider | JORDAN-WAGNER |
| First Name Of The Provider | DIANE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1429 N 6TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | TERRE HAUTE |
| Zip Code Of The Provider | 478041037 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Allergy/Immunology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 52 |
| Number Of Services | 4246 |
| Number Of Medicare Beneficiaries | 159 |
| Total Submitted Charge Amount | 93655 |
| Total Medicare Allowed Amount | 59206.5 |
| Total Medicare Payment Amount | 45020.29 |
| Total Medicare Standardized Payment Amount | 46773.81 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 29 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 1134 |
| Total Drug Medicare AllowedAmount | 757.01 |
| Total Drug Medicare PaymentAmount | 739.44 |
| Total Drug Medicare Standardized Payment Amount | 739.44 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 45 |
| Number Of Medical Services | 4217 |
| Number Of Medicare Beneficiaries With Medical Services | 159 |
| Total Medical Submitted Charge Amount | 92521 |
| Total Medical Medicare Allowed Amount | 58449.49 |
| Total Medical Medicare Payment Amount | 44280.85 |
| Total Medical Medicare Standardized Payment Amount | 46034.37 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 87 |
| Number Of Beneficiaries Age 75 to 84 | 34 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 117 |
| Number Of Male Beneficiaries | 42 |
| 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 | 132 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 27 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 26 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 25 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 45 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9457 |