| National Provider Identifier [NPI]: | 1518906221 |
| Last Name Of The Provider | BOLTHOUSE |
| First Name Of The Provider | JONATHAN |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4069 LAKE DR SE |
| Street Address 2 Of The Provider | S-313 |
| City Of The Provider | GRAND RAPIDS |
| Zip Code Of The Provider | 495468816 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Urology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 93 |
| Number Of Services | 1956 |
| Number Of Medicare Beneficiaries | 451 |
| Total Submitted Charge Amount | 365257 |
| Total Medicare Allowed Amount | 156747.37 |
| Total Medicare Payment Amount | 116440.5 |
| Total Medicare Standardized Payment Amount | 121939.17 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 392 |
| Number Of Medicare Beneficiaries With Drug Services | 16 |
| Total Drug Submitted ChargeAmount | 33540 |
| Total Drug Medicare AllowedAmount | 16828.92 |
| Total Drug Medicare PaymentAmount | 12870.78 |
| Total Drug Medicare Standardized Payment Amount | 12870.78 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 89 |
| Number Of Medical Services | 1564 |
| Number Of Medicare Beneficiaries With Medical Services | 450 |
| Total Medical Submitted Charge Amount | 331717 |
| Total Medical Medicare Allowed Amount | 139918.45 |
| Total Medical Medicare Payment Amount | 103569.72 |
| Total Medical Medicare Standardized Payment Amount | 109068.39 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 91 |
| Number Of Beneficiaries Age 65 to 74 | 149 |
| Number Of Beneficiaries Age 75 to 84 | 135 |
| Number Of Beneficiaries Age Greater 84 | 76 |
| Number Of Female Beneficiaries | 160 |
| Number Of Male Beneficiaries | 291 |
| Number Of Non Hispanic White Beneficiaries | 393 |
| Number Of Black or African American Beneficiaries | 41 |
| 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 | 354 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 97 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 18 |
| Percent Of With Heart Failure | 24 |
| Percent Of With Chronic Kidney Disease | 43 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.4199 |