| National Provider Identifier [NPI]: | 1063588580 |
| Last Name Of The Provider | FULTS |
| First Name Of The Provider | KENNETH |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4295 KINSEY DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | TYLER |
| Zip Code Of The Provider | 757031004 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Interventional Pain Management |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 2146 |
| Number Of Medicare Beneficiaries | 94 |
| Total Submitted Charge Amount | 286124 |
| Total Medicare Allowed Amount | 93633.51 |
| Total Medicare Payment Amount | 71258.06 |
| Total Medicare Standardized Payment Amount | 59560.88 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 636 |
| Number Of Medicare Beneficiaries With Drug Services | 37 |
| Total Drug Submitted ChargeAmount | 13625 |
| Total Drug Medicare AllowedAmount | 2458.66 |
| Total Drug Medicare PaymentAmount | 1925.68 |
| Total Drug Medicare Standardized Payment Amount | 1925.68 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 40 |
| Number Of Medical Services | 1510 |
| Number Of Medicare Beneficiaries With Medical Services | 94 |
| Total Medical Submitted Charge Amount | 272499 |
| Total Medical Medicare Allowed Amount | 91174.85 |
| Total Medical Medicare Payment Amount | 69332.38 |
| Total Medical Medicare Standardized Payment Amount | 57635.2 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 34 |
| Number Of Beneficiaries Age 65 to 74 | 30 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 50 |
| Number Of Male Beneficiaries | 44 |
| Number Of Non Hispanic White Beneficiaries | 72 |
| 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 | 66 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 28 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 44 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.3558 |