| National Provider Identifier [NPI]: | 1508045030 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | MICKEY |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 970 LAKELAND DR STE 40 |
| Street Address 2 Of The Provider | |
| City Of The Provider | JACKSON |
| Zip Code Of The Provider | 392164640 |
| State Code Of The Provider | MS |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Otolaryngology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 74 |
| Number Of Services | 1047 |
| Number Of Medicare Beneficiaries | 310 |
| Total Submitted Charge Amount | 274827 |
| Total Medicare Allowed Amount | 112561.55 |
| Total Medicare Payment Amount | 81116.53 |
| Total Medicare Standardized Payment Amount | 88685.72 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 84 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 754 |
| Total Drug Medicare AllowedAmount | 35.66 |
| Total Drug Medicare PaymentAmount | 23.96 |
| Total Drug Medicare Standardized Payment Amount | 23.96 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 72 |
| Number Of Medical Services | 963 |
| Number Of Medicare Beneficiaries With Medical Services | 310 |
| Total Medical Submitted Charge Amount | 274073 |
| Total Medical Medicare Allowed Amount | 112525.89 |
| Total Medical Medicare Payment Amount | 81092.57 |
| Total Medical Medicare Standardized Payment Amount | 88661.76 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 49 |
| Number Of Beneficiaries Age 65 to 74 | 139 |
| Number Of Beneficiaries Age 75 to 84 | 89 |
| Number Of Beneficiaries Age Greater 84 | 33 |
| Number Of Female Beneficiaries | 161 |
| Number Of Male Beneficiaries | 149 |
| Number Of Non Hispanic White Beneficiaries | 227 |
| 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 | 268 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 42 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 47 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.0416 |