| National Provider Identifier [NPI]: | 1396062899 |
| Last Name Of The Provider | FOSSUM |
| First Name Of The Provider | ERIK |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1701 N SENATE BLVD |
| Street Address 2 Of The Provider | ROOM DG412 |
| City Of The Provider | INDIANAPOLIS |
| Zip Code Of The Provider | 462021239 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 1749 |
| Number Of Medicare Beneficiaries | 1034 |
| Total Submitted Charge Amount | 695171 |
| Total Medicare Allowed Amount | 155164.15 |
| Total Medicare Payment Amount | 119225.68 |
| Total Medicare Standardized Payment Amount | 124934.64 |
| 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 | 31 |
| Number Of Medical Services | 1749 |
| Number Of Medicare Beneficiaries With Medical Services | 1034 |
| Total Medical Submitted Charge Amount | 695171 |
| Total Medical Medicare Allowed Amount | 155164.15 |
| Total Medical Medicare Payment Amount | 119225.68 |
| Total Medical Medicare Standardized Payment Amount | 124934.64 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 409 |
| Number Of Beneficiaries Age 65 to 74 | 228 |
| Number Of Beneficiaries Age 75 to 84 | 221 |
| Number Of Beneficiaries Age Greater 84 | 176 |
| Number Of Female Beneficiaries | 653 |
| Number Of Male Beneficiaries | 381 |
| Number Of Non Hispanic White Beneficiaries | 673 |
| Number Of Black or African American Beneficiaries | 331 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 15 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 548 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 486 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 18 |
| Percent Of With Asthma | 18 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 34 |
| Percent Of With Chronic Kidney Disease | 38 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 28 |
| Percent Of With Depression | 40 |
| Percent Of With Diabetes | 40 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 45 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 12 |
| Average HCC Risk Score Of Beneficiaries | 1.9777 |