| National Provider Identifier [NPI]: | 1619921475 |
| Last Name Of The Provider | FORMOLO |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1000 E PARIS AVE SE |
| Street Address 2 Of The Provider | STE 200 |
| City Of The Provider | GRAND RAPIDS |
| Zip Code Of The Provider | 495463680 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Cardiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 36 |
| Number Of Services | 1400 |
| Number Of Medicare Beneficiaries | 631 |
| Total Submitted Charge Amount | 289075 |
| Total Medicare Allowed Amount | 89714.92 |
| Total Medicare Payment Amount | 65659.2 |
| Total Medicare Standardized Payment Amount | 68261.17 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 36 |
| Number Of Medical Services | 1400 |
| Number Of Medicare Beneficiaries With Medical Services | 631 |
| Total Medical Submitted Charge Amount | 289075 |
| Total Medical Medicare Allowed Amount | 89714.92 |
| Total Medical Medicare Payment Amount | 65659.2 |
| Total Medical Medicare Standardized Payment Amount | 68261.17 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 121 |
| Number Of Beneficiaries Age 65 to 74 | 203 |
| Number Of Beneficiaries Age 75 to 84 | 200 |
| Number Of Beneficiaries Age Greater 84 | 107 |
| Number Of Female Beneficiaries | 319 |
| Number Of Male Beneficiaries | 312 |
| Number Of Non Hispanic White Beneficiaries | 508 |
| Number Of Black or African American Beneficiaries | 84 |
| 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 | 471 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 160 |
| Percent Of With Atrial Fibrillation | 29 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 44 |
| Percent Of With Chronic Kidney Disease | 42 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 25 |
| Percent Of With Depression | 30 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 59 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.8246 |