| National Provider Identifier [NPI]: | 1447310115 |
| Last Name Of The Provider | HENEISEN |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1214 N COLUMBIA AVE. |
| Street Address 2 Of The Provider | UNIT D |
| City Of The Provider | RINCON |
| Zip Code Of The Provider | 31326 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 26 |
| Number Of Services | 1346 |
| Number Of Medicare Beneficiaries | 277 |
| Total Submitted Charge Amount | 46446 |
| Total Medicare Allowed Amount | 38660.28 |
| Total Medicare Payment Amount | 20358.27 |
| Total Medicare Standardized Payment Amount | 25131.52 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 61 |
| Number Of Medicare Beneficiaries With Drug Services | 46 |
| Total Drug Submitted ChargeAmount | 1311 |
| Total Drug Medicare AllowedAmount | 459.56 |
| Total Drug Medicare PaymentAmount | 401.45 |
| Total Drug Medicare Standardized Payment Amount | 401.45 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 19 |
| Number Of Medical Services | 1285 |
| Number Of Medicare Beneficiaries With Medical Services | 277 |
| Total Medical Submitted Charge Amount | 45135 |
| Total Medical Medicare Allowed Amount | 38200.72 |
| Total Medical Medicare Payment Amount | 19956.82 |
| Total Medical Medicare Standardized Payment Amount | 24730.07 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 73 |
| Number Of Beneficiaries Age 65 to 74 | 155 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 138 |
| Number Of Male Beneficiaries | 139 |
| Number Of Non Hispanic White Beneficiaries | 249 |
| Number Of Black or African American Beneficiaries | |
| 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 | 227 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 50 |
| Percent Of With Atrial Fibrillation | 5 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 11 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 14 |
| Percent Of With Diabetes | 39 |
| Percent Of With Hyperlipidemia | 62 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 28 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 0.9178 |