| National Provider Identifier [NPI]: | 1043267461 |
| Last Name Of The Provider | DIETERICH |
| First Name Of The Provider | MARK |
| 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 | 2650 RIDGE AVE |
| Street Address 2 Of The Provider | EVANSTON HOSPITAL RM 1210 |
| City Of The Provider | EVANSTON |
| Zip Code Of The Provider | 602011718 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pathology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 29 |
| Number Of Services | 2728 |
| Number Of Medicare Beneficiaries | 1199 |
| Total Submitted Charge Amount | 433062 |
| Total Medicare Allowed Amount | 107081.52 |
| Total Medicare Payment Amount | 81595.2 |
| Total Medicare Standardized Payment Amount | 73487.97 |
| 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 | 29 |
| Number Of Medical Services | 2728 |
| Number Of Medicare Beneficiaries With Medical Services | 1199 |
| Total Medical Submitted Charge Amount | 433062 |
| Total Medical Medicare Allowed Amount | 107081.52 |
| Total Medical Medicare Payment Amount | 81595.2 |
| Total Medical Medicare Standardized Payment Amount | 73487.97 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 74 |
| Number Of Beneficiaries Age 65 to 74 | 513 |
| Number Of Beneficiaries Age 75 to 84 | 438 |
| Number Of Beneficiaries Age Greater 84 | 174 |
| Number Of Female Beneficiaries | 678 |
| Number Of Male Beneficiaries | 521 |
| Number Of Non Hispanic White Beneficiaries | 1023 |
| Number Of Black or African American Beneficiaries | 50 |
| Number Of AsianPacific Islander Beneficiaries | 54 |
| Number Of Hispanic Beneficiaries | 34 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 38 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1046 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 153 |
| Percent Of With Atrial Fibrillation | 16 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 24 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 56 |
| Percent Of With Hypertension | 63 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.31 |