| National Provider Identifier [NPI]: | 1881631075 |
| Last Name Of The Provider | WICHTERMAN |
| First Name Of The Provider | LISA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3050 MONTVALE DR STE A |
| Street Address 2 Of The Provider | |
| City Of The Provider | SPRINGFIELD |
| Zip Code Of The Provider | 627046924 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 60 |
| Number Of Services | 1864 |
| Number Of Medicare Beneficiaries | 1043 |
| Total Submitted Charge Amount | 278902.06 |
| Total Medicare Allowed Amount | 66043.47 |
| Total Medicare Payment Amount | 54870.98 |
| Total Medicare Standardized Payment Amount | 55578.64 |
| 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 | 60 |
| Number Of Medical Services | 1864 |
| Number Of Medicare Beneficiaries With Medical Services | 1043 |
| Total Medical Submitted Charge Amount | 278902.06 |
| Total Medical Medicare Allowed Amount | 66043.47 |
| Total Medical Medicare Payment Amount | 54870.98 |
| Total Medical Medicare Standardized Payment Amount | 55578.64 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 147 |
| Number Of Beneficiaries Age 65 to 74 | 541 |
| Number Of Beneficiaries Age 75 to 84 | 288 |
| Number Of Beneficiaries Age Greater 84 | 67 |
| Number Of Female Beneficiaries | 989 |
| Number Of Male Beneficiaries | 54 |
| Number Of Non Hispanic White Beneficiaries | 979 |
| Number Of Black or African American Beneficiaries | 42 |
| 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 | 859 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 184 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 22 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 12 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 23 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 2 |
| Average HCC Risk Score Of Beneficiaries | 0.9456 |