| National Provider Identifier [NPI]: | 1821014341 |
| Last Name Of The Provider | HARDJASUDARMA |
| First Name Of The Provider | MARDJOHAN |
| 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 | 1501 KINGS HWY |
| Street Address 2 Of The Provider | DEPARTMENT OF RADIOLOGY |
| City Of The Provider | SHREVEPORT |
| Zip Code Of The Provider | 711034228 |
| State Code Of The Provider | LA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 85 |
| Number Of Services | 2273 |
| Number Of Medicare Beneficiaries | 1320 |
| Total Submitted Charge Amount | 745680 |
| Total Medicare Allowed Amount | 108254.99 |
| Total Medicare Payment Amount | 76602.57 |
| Total Medicare Standardized Payment Amount | 81992.7 |
| 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 | 85 |
| Number Of Medical Services | 2273 |
| Number Of Medicare Beneficiaries With Medical Services | 1320 |
| Total Medical Submitted Charge Amount | 745680 |
| Total Medical Medicare Allowed Amount | 108254.99 |
| Total Medical Medicare Payment Amount | 76602.57 |
| Total Medical Medicare Standardized Payment Amount | 81992.7 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 524 |
| Number Of Beneficiaries Age 65 to 74 | 470 |
| Number Of Beneficiaries Age 75 to 84 | 235 |
| Number Of Beneficiaries Age Greater 84 | 91 |
| Number Of Female Beneficiaries | 726 |
| Number Of Male Beneficiaries | 594 |
| Number Of Non Hispanic White Beneficiaries | 659 |
| Number Of Black or African American Beneficiaries | 640 |
| 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 | 602 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 718 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 33 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 39 |
| Percent Of With Hyperlipidemia | 47 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 10 |
| Percent Of With Stroke | 22 |
| Average HCC Risk Score Of Beneficiaries | 1.5672 |