| National Provider Identifier [NPI]: | 1770794992 |
| Last Name Of The Provider | FORTIN |
| First Name Of The Provider | LISA |
| 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 | 2799 W GRAND BLVD |
| Street Address 2 Of The Provider | HENRY FORD HOSPITAL |
| City Of The Provider | DETROIT |
| Zip Code Of The Provider | 482022608 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 217 |
| Number Of Services | 4615 |
| Number Of Medicare Beneficiaries | 2907 |
| Total Submitted Charge Amount | 452724.05 |
| Total Medicare Allowed Amount | 163813.14 |
| Total Medicare Payment Amount | 127086.2 |
| Total Medicare Standardized Payment Amount | 131504.36 |
| 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 | 217 |
| Number Of Medical Services | 4615 |
| Number Of Medicare Beneficiaries With Medical Services | 2907 |
| Total Medical Submitted Charge Amount | 452724.05 |
| Total Medical Medicare Allowed Amount | 163813.14 |
| Total Medical Medicare Payment Amount | 127086.2 |
| Total Medical Medicare Standardized Payment Amount | 131504.36 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 533 |
| Number Of Beneficiaries Age 65 to 74 | 1151 |
| Number Of Beneficiaries Age 75 to 84 | 817 |
| Number Of Beneficiaries Age Greater 84 | 406 |
| Number Of Female Beneficiaries | 1690 |
| Number Of Male Beneficiaries | 1217 |
| Number Of Non Hispanic White Beneficiaries | 2753 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 114 |
| Number Of Beneficiaries With Race Not Else where Classified | 25 |
| Number Of Beneficiaries With Medicare Only Entitlement | 2252 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 655 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 25 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 27 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.3361 |