| National Provider Identifier [NPI]: | 1457376758 |
| Last Name Of The Provider | BANTAMOI |
| First Name Of The Provider | EDWARD |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2502 S. ASHLAND AVE. |
| Street Address 2 Of The Provider | |
| City Of The Provider | GREEN BAY |
| Zip Code Of The Provider | 54304 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 64 |
| Number Of Services | 972 |
| Number Of Medicare Beneficiaries | 173 |
| Total Submitted Charge Amount | 126262 |
| Total Medicare Allowed Amount | 38483.22 |
| Total Medicare Payment Amount | 27071.17 |
| Total Medicare Standardized Payment Amount | 28180.06 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 33 |
| Number Of Medicare Beneficiaries With Drug Services | 32 |
| Total Drug Submitted ChargeAmount | 1500.75 |
| Total Drug Medicare AllowedAmount | 1021.52 |
| Total Drug Medicare PaymentAmount | 1001.06 |
| Total Drug Medicare Standardized Payment Amount | 1001.06 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 59 |
| Number Of Medical Services | 939 |
| Number Of Medicare Beneficiaries With Medical Services | 173 |
| Total Medical Submitted Charge Amount | 124761.25 |
| Total Medical Medicare Allowed Amount | 37461.7 |
| Total Medical Medicare Payment Amount | 26070.11 |
| Total Medical Medicare Standardized Payment Amount | 27179 |
| Average Age Of Beneficiaries | 62 |
| Number Of Beneficiaries Age Less65 | 75 |
| Number Of Beneficiaries Age 65 to 74 | 55 |
| Number Of Beneficiaries Age 75 to 84 | 25 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 85 |
| Number Of Male Beneficiaries | 88 |
| Number Of Non Hispanic White Beneficiaries | 141 |
| Number Of Black or African American Beneficiaries | 11 |
| 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 | 96 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 77 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 45 |
| Percent Of With Hypertension | 47 |
| Percent Of With Ischemic Heart Disease | 22 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 19 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9054 |