| National Provider Identifier [NPI]: | 1528152170 |
| Last Name Of The Provider | ECONOMOU |
| First Name Of The Provider | THEMISTOCLES |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3300 EDINBOROUGH WAY |
| Street Address 2 Of The Provider | SUITE 505 |
| City Of The Provider | EDINA |
| Zip Code Of The Provider | 55403 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Plastic and Reconstructive Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 63 |
| Number Of Services | 562 |
| Number Of Medicare Beneficiaries | 180 |
| Total Submitted Charge Amount | 271972 |
| Total Medicare Allowed Amount | 106167.46 |
| Total Medicare Payment Amount | 82258.44 |
| Total Medicare Standardized Payment Amount | 84293.32 |
| 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 | 63 |
| Number Of Medical Services | 562 |
| Number Of Medicare Beneficiaries With Medical Services | 180 |
| Total Medical Submitted Charge Amount | 271972 |
| Total Medical Medicare Allowed Amount | 106167.46 |
| Total Medical Medicare Payment Amount | 82258.44 |
| Total Medical Medicare Standardized Payment Amount | 84293.32 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 19 |
| Number Of Beneficiaries Age 65 to 74 | 82 |
| Number Of Beneficiaries Age 75 to 84 | 53 |
| Number Of Beneficiaries Age Greater 84 | 26 |
| Number Of Female Beneficiaries | 91 |
| Number Of Male Beneficiaries | 89 |
| Number Of Non Hispanic White Beneficiaries | 169 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 161 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 16 |
| Percent Of With Hyperlipidemia | 33 |
| Percent Of With Hypertension | 45 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 19 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0221 |