| National Provider Identifier [NPI]: | 1427232412 |
| Last Name Of The Provider | DIETHELM |
| First Name Of The Provider | JESSICA |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1725 W HARRISON ST |
| Street Address 2 Of The Provider | SUITE 263 |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606123841 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 25 |
| Number Of Services | 1140 |
| Number Of Medicare Beneficiaries | 322 |
| Total Submitted Charge Amount | 153464.56 |
| Total Medicare Allowed Amount | 87213.14 |
| Total Medicare Payment Amount | 62842.67 |
| Total Medicare Standardized Payment Amount | 59676.12 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 83 |
| Number Of Medicare Beneficiaries With Drug Services | 74 |
| Total Drug Submitted ChargeAmount | 3615 |
| Total Drug Medicare AllowedAmount | 1795.88 |
| Total Drug Medicare PaymentAmount | 1759.99 |
| Total Drug Medicare Standardized Payment Amount | 1759.99 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 1057 |
| Number Of Medicare Beneficiaries With Medical Services | 322 |
| Total Medical Submitted Charge Amount | 149849.56 |
| Total Medical Medicare Allowed Amount | 85417.26 |
| Total Medical Medicare Payment Amount | 61082.68 |
| Total Medical Medicare Standardized Payment Amount | 57916.13 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 126 |
| Number Of Beneficiaries Age 65 to 74 | 130 |
| Number Of Beneficiaries Age 75 to 84 | 47 |
| Number Of Beneficiaries Age Greater 84 | 19 |
| Number Of Female Beneficiaries | 244 |
| Number Of Male Beneficiaries | 78 |
| Number Of Non Hispanic White Beneficiaries | 79 |
| Number Of Black or African American Beneficiaries | 185 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 46 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 158 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 164 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 24 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 43 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 51 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.8032 |