| National Provider Identifier [NPI]: | 1740391044 |
| Last Name Of The Provider | ELLISON |
| First Name Of The Provider | WESLEY |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3502 FRANKLIN AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | BISMARCK |
| Zip Code Of The Provider | 585030761 |
| State Code Of The Provider | ND |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pathology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 26 |
| Number Of Services | 3323 |
| Number Of Medicare Beneficiaries | 1321 |
| Total Submitted Charge Amount | 390483 |
| Total Medicare Allowed Amount | 151924.85 |
| Total Medicare Payment Amount | 108221.49 |
| Total Medicare Standardized Payment Amount | 83964.25 |
| 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 | 26 |
| Number Of Medical Services | 3323 |
| Number Of Medicare Beneficiaries With Medical Services | 1321 |
| Total Medical Submitted Charge Amount | 390483 |
| Total Medical Medicare Allowed Amount | 151924.85 |
| Total Medical Medicare Payment Amount | 108221.49 |
| Total Medical Medicare Standardized Payment Amount | 83964.25 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 116 |
| Number Of Beneficiaries Age 65 to 74 | 614 |
| Number Of Beneficiaries Age 75 to 84 | 436 |
| Number Of Beneficiaries Age Greater 84 | 155 |
| Number Of Female Beneficiaries | 685 |
| Number Of Male Beneficiaries | 636 |
| Number Of Non Hispanic White Beneficiaries | 1263 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 35 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 1148 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 173 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 19 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 2 |
| Average HCC Risk Score Of Beneficiaries | 1.0759 |