| National Provider Identifier [NPI]: | 1003836610 |
| Last Name Of The Provider | SUSANTO |
| First Name Of The Provider | IRAWAN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1223 16TH ST |
| Street Address 2 Of The Provider | SUITE 3400 |
| City Of The Provider | SANTA MONICA |
| Zip Code Of The Provider | 904041217 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pulmonary Disease |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 55 |
| Number Of Services | 1009 |
| Number Of Medicare Beneficiaries | 295 |
| Total Submitted Charge Amount | 609344.35 |
| Total Medicare Allowed Amount | 145841.5 |
| Total Medicare Payment Amount | 112746.95 |
| Total Medicare Standardized Payment Amount | 105246.51 |
| Drug Suppress Indicator | * |
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| Total Drug Submitted ChargeAmount | |
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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 | 55 |
| Number Of Beneficiaries Age 65 to 74 | 101 |
| Number Of Beneficiaries Age 75 to 84 | 74 |
| Number Of Beneficiaries Age Greater 84 | 65 |
| Number Of Female Beneficiaries | 152 |
| Number Of Male Beneficiaries | 143 |
| Number Of Non Hispanic White Beneficiaries | 183 |
| Number Of Black or African American Beneficiaries | 31 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 45 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 185 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 110 |
| Percent Of With Atrial Fibrillation | 23 |
| Percent Of With Alzheimers Disease or Dementia | 21 |
| Percent Of With Asthma | 18 |
| Percent Of With Cancer | 23 |
| Percent Of With Heart Failure | 50 |
| Percent Of With Chronic Kidney Disease | 66 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 42 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 49 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 64 |
| Percent Of With Osteoporosis | 19 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 52 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 10 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 3.2903 |