| National Provider Identifier [NPI]: | 1114975018 |
| Last Name Of The Provider | SUMMERLIN |
| First Name Of The Provider | DON-JOHN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | D.M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 9292 N MERIDIAN ST |
| Street Address 2 Of The Provider | 210 |
| City Of The Provider | INDIANAPOLIS |
| Zip Code Of The Provider | 462601857 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Oral Surgery (dentists only) |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 16 |
| Number Of Services | 1044.2 |
| Number Of Medicare Beneficiaries | 234 |
| Total Submitted Charge Amount | 235868 |
| Total Medicare Allowed Amount | 43825.24 |
| Total Medicare Payment Amount | 33981.45 |
| Total Medicare Standardized Payment Amount | 26968.84 |
| 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 | 16 |
| Number Of Medical Services | 1044.2 |
| Number Of Medicare Beneficiaries With Medical Services | 234 |
| Total Medical Submitted Charge Amount | 235868 |
| Total Medical Medicare Allowed Amount | 43825.24 |
| Total Medical Medicare Payment Amount | 33981.45 |
| Total Medical Medicare Standardized Payment Amount | 26968.84 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 76 |
| Number Of Beneficiaries Age 65 to 74 | 88 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 106 |
| Number Of Male Beneficiaries | 128 |
| Number Of Non Hispanic White Beneficiaries | 187 |
| 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 | 152 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 82 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 18 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 29 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.0551 |