| National Provider Identifier [NPI]: | 1962400382 |
| Last Name Of The Provider | HARTSOUGH |
| First Name Of The Provider | NICOLE |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 7402 E RIVERSIDE BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | LOVES PARK |
| Zip Code Of The Provider | 611115630 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Dermatology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 61 |
| Number Of Services | 4214 |
| Number Of Medicare Beneficiaries | 798 |
| Total Submitted Charge Amount | 732055.2 |
| Total Medicare Allowed Amount | 364479.05 |
| Total Medicare Payment Amount | 269511.63 |
| Total Medicare Standardized Payment Amount | 288628.2 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 145 |
| Number Of Medicare Beneficiaries With Drug Services | 84 |
| Total Drug Submitted ChargeAmount | 49140 |
| Total Drug Medicare AllowedAmount | 34962.63 |
| Total Drug Medicare PaymentAmount | 27205.03 |
| Total Drug Medicare Standardized Payment Amount | 27205.03 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 59 |
| Number Of Medical Services | 4069 |
| Number Of Medicare Beneficiaries With Medical Services | 798 |
| Total Medical Submitted Charge Amount | 682915.2 |
| Total Medical Medicare Allowed Amount | 329516.42 |
| Total Medical Medicare Payment Amount | 242306.6 |
| Total Medical Medicare Standardized Payment Amount | 261423.17 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 46 |
| Number Of Beneficiaries Age 65 to 74 | 355 |
| Number Of Beneficiaries Age 75 to 84 | 268 |
| Number Of Beneficiaries Age Greater 84 | 129 |
| Number Of Female Beneficiaries | 417 |
| Number Of Male Beneficiaries | 381 |
| Number Of Non Hispanic White Beneficiaries | 773 |
| Number Of Black or African American Beneficiaries | |
| 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 | 762 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 36 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 3 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 11 |
| Percent Of With Diabetes | 22 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 56 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 2 |
| Average HCC Risk Score Of Beneficiaries | 0.9421 |