| National Provider Identifier [NPI]: | 1518166073 |
| Last Name Of The Provider | GORBACHOVA |
| First Name Of The Provider | TETYANA |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3350 LA JOLLA VILLAGE DR |
| Street Address 2 Of The Provider | 114 - BONEPIT |
| City Of The Provider | SAN DIEGO |
| Zip Code Of The Provider | 921610002 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 107 |
| Number Of Services | 1825 |
| Number Of Medicare Beneficiaries | 1328 |
| Total Submitted Charge Amount | 248880 |
| Total Medicare Allowed Amount | 57364.23 |
| Total Medicare Payment Amount | 41753.07 |
| Total Medicare Standardized Payment Amount | 40402.97 |
| 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 | 107 |
| Number Of Medical Services | 1825 |
| Number Of Medicare Beneficiaries With Medical Services | 1328 |
| Total Medical Submitted Charge Amount | 248880 |
| Total Medical Medicare Allowed Amount | 57364.23 |
| Total Medical Medicare Payment Amount | 41753.07 |
| Total Medical Medicare Standardized Payment Amount | 40402.97 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 419 |
| Number Of Beneficiaries Age 65 to 74 | 461 |
| Number Of Beneficiaries Age 75 to 84 | 268 |
| Number Of Beneficiaries Age Greater 84 | 180 |
| Number Of Female Beneficiaries | 731 |
| Number Of Male Beneficiaries | 597 |
| Number Of Non Hispanic White Beneficiaries | 515 |
| Number Of Black or African American Beneficiaries | 696 |
| Number Of AsianPacific Islander Beneficiaries | 33 |
| Number Of Hispanic Beneficiaries | 65 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 672 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 656 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 23 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 39 |
| Percent Of With Chronic Kidney Disease | 46 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 49 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 48 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 53 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 13 |
| Average HCC Risk Score Of Beneficiaries | 2.2214 |