| National Provider Identifier [NPI]: | 1831136019 |
| Last Name Of The Provider | JACOB |
| First Name Of The Provider | SUSAN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.C. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 303 E ARMY TRAIL RD |
| Street Address 2 Of The Provider | STE 410A |
| City Of The Provider | BLOOMINGDALE |
| Zip Code Of The Provider | 601082169 |
| 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 | 57 |
| Number Of Services | 433 |
| Number Of Medicare Beneficiaries | 192 |
| Total Submitted Charge Amount | 52315 |
| Total Medicare Allowed Amount | 29989.17 |
| Total Medicare Payment Amount | 19571.12 |
| Total Medicare Standardized Payment Amount | 18862.18 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 61 |
| Number Of Medicare Beneficiaries With Drug Services | 29 |
| Total Drug Submitted ChargeAmount | 1533 |
| Total Drug Medicare AllowedAmount | 340.38 |
| Total Drug Medicare PaymentAmount | 256.22 |
| Total Drug Medicare Standardized Payment Amount | 256.22 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 48 |
| Number Of Medical Services | 372 |
| Number Of Medicare Beneficiaries With Medical Services | 192 |
| Total Medical Submitted Charge Amount | 50782 |
| Total Medical Medicare Allowed Amount | 29648.79 |
| Total Medical Medicare Payment Amount | 19314.9 |
| Total Medical Medicare Standardized Payment Amount | 18605.96 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 36 |
| Number Of Beneficiaries Age 65 to 74 | 100 |
| Number Of Beneficiaries Age 75 to 84 | 42 |
| Number Of Beneficiaries Age Greater 84 | 14 |
| Number Of Female Beneficiaries | 112 |
| Number Of Male Beneficiaries | 80 |
| Number Of Non Hispanic White Beneficiaries | 144 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 15 |
| Number Of Hispanic Beneficiaries | 18 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 155 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 37 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8785 |