| National Provider Identifier [NPI]: | 1669668497 |
| Last Name Of The Provider | FANGTHAM |
| First Name Of The Provider | MONTHIDA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | DOIM RHEUMATOLOGY |
| Street Address 2 Of The Provider | 1 UNIVERSITY OF NEW MEXICO MSC 10-5550 |
| City Of The Provider | ALBUQUERQUE |
| Zip Code Of The Provider | 871310001 |
| State Code Of The Provider | NM |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Rheumatology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 21 |
| Number Of Services | 609 |
| Number Of Medicare Beneficiaries | 135 |
| Total Submitted Charge Amount | 73164 |
| Total Medicare Allowed Amount | 34329.06 |
| Total Medicare Payment Amount | 26494.02 |
| Total Medicare Standardized Payment Amount | 25078.34 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 289 |
| Number Of Medicare Beneficiaries With Drug Services | 34 |
| Total Drug Submitted ChargeAmount | 12032 |
| Total Drug Medicare AllowedAmount | 3174.26 |
| Total Drug Medicare PaymentAmount | 2490.91 |
| Total Drug Medicare Standardized Payment Amount | 2490.91 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 16 |
| Number Of Medical Services | 320 |
| Number Of Medicare Beneficiaries With Medical Services | 135 |
| Total Medical Submitted Charge Amount | 61132 |
| Total Medical Medicare Allowed Amount | 31154.8 |
| Total Medical Medicare Payment Amount | 24003.11 |
| Total Medical Medicare Standardized Payment Amount | 22587.43 |
| Average Age Of Beneficiaries | 64 |
| Number Of Beneficiaries Age Less65 | 69 |
| Number Of Beneficiaries Age 65 to 74 | 44 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 95 |
| Number Of Male Beneficiaries | 40 |
| Number Of Non Hispanic White Beneficiaries | 27 |
| Number Of Black or African American Beneficiaries | 90 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 48 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 87 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 19 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 30 |
| Percent Of With Chronic Kidney Disease | 36 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 24 |
| Percent Of With Diabetes | 43 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 16 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 11 |
| Average HCC Risk Score Of Beneficiaries | 1.6662 |