| National Provider Identifier [NPI]: | 1215043229 |
| Last Name Of The Provider | JOHANSON |
| First Name Of The Provider | GARY |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 500 DOYLE PARK DR |
| Street Address 2 Of The Provider | SUITE G04 |
| City Of The Provider | SANTA ROSA |
| Zip Code Of The Provider | 954054558 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Hospice and Palliative Care |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 42 |
| Number Of Services | 1488 |
| Number Of Medicare Beneficiaries | 101 |
| Total Submitted Charge Amount | 112338.89 |
| Total Medicare Allowed Amount | 58616.67 |
| Total Medicare Payment Amount | 45135.23 |
| Total Medicare Standardized Payment Amount | 43711.59 |
| Drug Suppress Indicator | * |
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| Number Of Medicare Beneficiaries With Drug Services | |
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| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
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| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
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| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 23 |
| Number Of Beneficiaries Age 65 to 74 | 28 |
| Number Of Beneficiaries Age 75 to 84 | 27 |
| Number Of Beneficiaries Age Greater 84 | 23 |
| Number Of Female Beneficiaries | 57 |
| Number Of Male Beneficiaries | 44 |
| Number Of Non Hispanic White Beneficiaries | 89 |
| Number Of Black or African American Beneficiaries | 0 |
| 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 | 65 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 36 |
| Percent Of With Atrial Fibrillation | 22 |
| Percent Of With Alzheimers Disease or Dementia | 25 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 32 |
| Percent Of With Heart Failure | 50 |
| Percent Of With Chronic Kidney Disease | 49 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 40 |
| Percent Of With Depression | 41 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 56 |
| Percent Of With Osteoporosis | 18 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 12 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.865 |