| National Provider Identifier [NPI]: | 1326097809 |
| Last Name Of The Provider | WALLER |
| First Name Of The Provider | ROBERT |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 75 SHELDON BLVD SE |
| Street Address 2 Of The Provider | |
| City Of The Provider | GRAND RAPIDS |
| Zip Code Of The Provider | 495034224 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Addiction Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 24 |
| Number Of Services | 2361 |
| Number Of Medicare Beneficiaries | 43 |
| Total Submitted Charge Amount | 54849 |
| Total Medicare Allowed Amount | 35093.23 |
| Total Medicare Payment Amount | 26257.25 |
| Total Medicare Standardized Payment Amount | 28366.8 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 1918 |
| Number Of Medicare Beneficiaries With Drug Services | 13 |
| Total Drug Submitted ChargeAmount | 11559 |
| Total Drug Medicare AllowedAmount | 5294.41 |
| Total Drug Medicare PaymentAmount | 4153.58 |
| Total Drug Medicare Standardized Payment Amount | 4153.58 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 16 |
| Number Of Medical Services | 443 |
| Number Of Medicare Beneficiaries With Medical Services | 43 |
| Total Medical Submitted Charge Amount | 43290 |
| Total Medical Medicare Allowed Amount | 29798.82 |
| Total Medical Medicare Payment Amount | 22103.67 |
| Total Medical Medicare Standardized Payment Amount | 24213.22 |
| Average Age Of Beneficiaries | 42 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 24 |
| Number Of Male Beneficiaries | 19 |
| Number Of Non Hispanic White Beneficiaries | 32 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 0 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 72 |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | 26 |
| Percent Of With Hypertension | 30 |
| Percent Of With Ischemic Heart Disease | |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 1.9691 |