| National Provider Identifier [NPI]: | 1033131446 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | RALPH |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2701 W 68TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606291813 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 8 |
| Number Of Services | 204 |
| Number Of Medicare Beneficiaries | 193 |
| Total Submitted Charge Amount | 111712 |
| Total Medicare Allowed Amount | 31457.77 |
| Total Medicare Payment Amount | 23403.69 |
| Total Medicare Standardized Payment Amount | 21459.98 |
| 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 | 8 |
| Number Of Medical Services | 204 |
| Number Of Medicare Beneficiaries With Medical Services | 193 |
| Total Medical Submitted Charge Amount | 111712 |
| Total Medical Medicare Allowed Amount | 31457.77 |
| Total Medical Medicare Payment Amount | 23403.69 |
| Total Medical Medicare Standardized Payment Amount | 21459.98 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 57 |
| Number Of Beneficiaries Age 65 to 74 | 68 |
| Number Of Beneficiaries Age 75 to 84 | 54 |
| Number Of Beneficiaries Age Greater 84 | 14 |
| Number Of Female Beneficiaries | 118 |
| Number Of Male Beneficiaries | 75 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | 167 |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 12 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 87 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 106 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 22 |
| Percent Of With Asthma | 26 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 41 |
| Percent Of With Chronic Kidney Disease | 40 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 32 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 52 |
| Percent Of With Hyperlipidemia | 56 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 57 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 12 |
| Average HCC Risk Score Of Beneficiaries | 2.0798 |