| National Provider Identifier [NPI]: | 1285674671 |
| Last Name Of The Provider | FORSHA |
| First Name Of The Provider | DOUGLASS |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3570 W 9000 S |
| Street Address 2 Of The Provider | SUITE 220 |
| City Of The Provider | WEST JORDAN |
| Zip Code Of The Provider | 840888869 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Dermatology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 51 |
| Number Of Services | 2007 |
| Number Of Medicare Beneficiaries | 499 |
| Total Submitted Charge Amount | 215618.64 |
| Total Medicare Allowed Amount | 135229.71 |
| Total Medicare Payment Amount | 98113.32 |
| Total Medicare Standardized Payment Amount | 103045.98 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 399 |
| Number Of Medicare Beneficiaries With Drug Services | 81 |
| Total Drug Submitted ChargeAmount | 5822.4 |
| Total Drug Medicare AllowedAmount | 5026.32 |
| Total Drug Medicare PaymentAmount | 3779.11 |
| Total Drug Medicare Standardized Payment Amount | 3779.11 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 47 |
| Number Of Medical Services | 1608 |
| Number Of Medicare Beneficiaries With Medical Services | 499 |
| Total Medical Submitted Charge Amount | 209796.24 |
| Total Medical Medicare Allowed Amount | 130203.39 |
| Total Medical Medicare Payment Amount | 94334.21 |
| Total Medical Medicare Standardized Payment Amount | 99266.87 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 55 |
| Number Of Beneficiaries Age 65 to 74 | 257 |
| Number Of Beneficiaries Age 75 to 84 | 126 |
| Number Of Beneficiaries Age Greater 84 | 61 |
| Number Of Female Beneficiaries | 276 |
| Number Of Male Beneficiaries | 223 |
| Number Of Non Hispanic White Beneficiaries | 471 |
| Number Of Black or African American Beneficiaries | 0 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 14 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 449 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 50 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 32 |
| Percent Of With Hypertension | 48 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9435 |