| National Provider Identifier [NPI]: | 1538262837 |
| Last Name Of The Provider | VALLECILLO |
| First Name Of The Provider | JORGE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1319 LIGHT ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | BALTIMORE |
| Zip Code Of The Provider | 212304307 |
| State Code Of The Provider | MD |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 27 |
| Number Of Services | 1850 |
| Number Of Medicare Beneficiaries | 267 |
| Total Submitted Charge Amount | 177000 |
| Total Medicare Allowed Amount | 156902.97 |
| Total Medicare Payment Amount | 125078.76 |
| Total Medicare Standardized Payment Amount | 119691.81 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 298 |
| Number Of Medicare Beneficiaries With Drug Services | 184 |
| Total Drug Submitted ChargeAmount | 31985 |
| Total Drug Medicare AllowedAmount | 23950.38 |
| Total Drug Medicare PaymentAmount | 23470.89 |
| Total Drug Medicare Standardized Payment Amount | 23470.89 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 23 |
| Number Of Medical Services | 1552 |
| Number Of Medicare Beneficiaries With Medical Services | 267 |
| Total Medical Submitted Charge Amount | 145015 |
| Total Medical Medicare Allowed Amount | 132952.59 |
| Total Medical Medicare Payment Amount | 101607.87 |
| Total Medical Medicare Standardized Payment Amount | 96220.92 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 42 |
| Number Of Beneficiaries Age 65 to 74 | 112 |
| Number Of Beneficiaries Age 75 to 84 | 86 |
| Number Of Beneficiaries Age Greater 84 | 27 |
| Number Of Female Beneficiaries | 162 |
| Number Of Male Beneficiaries | 105 |
| Number Of Non Hispanic White Beneficiaries | 224 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 20 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 208 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 59 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 35 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 37 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1362 |