| National Provider Identifier [NPI]: | 1962484733 |
| Last Name Of The Provider | WALLIS |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2108 HUNTER RD |
| Street Address 2 Of The Provider | SUITE 116 |
| City Of The Provider | SAN MARCOS |
| Zip Code Of The Provider | 786665156 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 34 |
| Number Of Services | 937 |
| Number Of Medicare Beneficiaries | 179 |
| Total Submitted Charge Amount | 120496 |
| Total Medicare Allowed Amount | 65802.64 |
| Total Medicare Payment Amount | 47840.71 |
| Total Medicare Standardized Payment Amount | 53790.42 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 72 |
| Number Of Medicare Beneficiaries With Drug Services | 52 |
| Total Drug Submitted ChargeAmount | 2430 |
| Total Drug Medicare AllowedAmount | 1550.96 |
| Total Drug Medicare PaymentAmount | 1512.07 |
| Total Drug Medicare Standardized Payment Amount | 1512.07 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 29 |
| Number Of Medical Services | 865 |
| Number Of Medicare Beneficiaries With Medical Services | 179 |
| Total Medical Submitted Charge Amount | 118066 |
| Total Medical Medicare Allowed Amount | 64251.68 |
| Total Medical Medicare Payment Amount | 46328.64 |
| Total Medical Medicare Standardized Payment Amount | 52278.35 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 42 |
| Number Of Beneficiaries Age 65 to 74 | 92 |
| Number Of Beneficiaries Age 75 to 84 | 33 |
| Number Of Beneficiaries Age Greater 84 | 12 |
| Number Of Female Beneficiaries | 68 |
| Number Of Male Beneficiaries | 111 |
| Number Of Non Hispanic White Beneficiaries | 156 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 12 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 6 |
| Percent Of With Depression | 9 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 56 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 23 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8415 |