| National Provider Identifier [NPI]: | 1811198344 |
| Last Name Of The Provider | BUDIHARDJO |
| First Name Of The Provider | PHILIP |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1969 W HART RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | BELOIT |
| Zip Code Of The Provider | 535112230 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 159 |
| Number Of Services | 4455 |
| Number Of Medicare Beneficiaries | 2284 |
| Total Submitted Charge Amount | 997136 |
| Total Medicare Allowed Amount | 136811.57 |
| Total Medicare Payment Amount | 102931.73 |
| Total Medicare Standardized Payment Amount | 107151.82 |
| 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 | 159 |
| Number Of Medical Services | 4455 |
| Number Of Medicare Beneficiaries With Medical Services | 2284 |
| Total Medical Submitted Charge Amount | 997136 |
| Total Medical Medicare Allowed Amount | 136811.57 |
| Total Medical Medicare Payment Amount | 102931.73 |
| Total Medical Medicare Standardized Payment Amount | 107151.82 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 479 |
| Number Of Beneficiaries Age 65 to 74 | 764 |
| Number Of Beneficiaries Age 75 to 84 | 673 |
| Number Of Beneficiaries Age Greater 84 | 368 |
| Number Of Female Beneficiaries | 1422 |
| Number Of Male Beneficiaries | 862 |
| Number Of Non Hispanic White Beneficiaries | 1978 |
| Number Of Black or African American Beneficiaries | 220 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 54 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 18 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1622 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 662 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 23 |
| Percent Of With Chronic Kidney Disease | 30 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 62 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.4493 |