| National Provider Identifier [NPI]: | 1376650572 |
| Last Name Of The Provider | FORNETTI |
| First Name Of The Provider | WILLA |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | DO, MS |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 635 W OSHKOSH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | RIPON |
| Zip Code Of The Provider | 549711040 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Sports Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 27 |
| Number Of Services | 614 |
| Number Of Medicare Beneficiaries | 88 |
| Total Submitted Charge Amount | 73908 |
| Total Medicare Allowed Amount | 21345.43 |
| Total Medicare Payment Amount | 15830.95 |
| Total Medicare Standardized Payment Amount | 16190.74 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 332 |
| Number Of Medicare Beneficiaries With Drug Services | 32 |
| Total Drug Submitted ChargeAmount | 6042 |
| Total Drug Medicare AllowedAmount | 1982 |
| Total Drug Medicare PaymentAmount | 1461.08 |
| Total Drug Medicare Standardized Payment Amount | 1461.08 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 22 |
| Number Of Medical Services | 282 |
| Number Of Medicare Beneficiaries With Medical Services | 88 |
| Total Medical Submitted Charge Amount | 67866 |
| Total Medical Medicare Allowed Amount | 19363.43 |
| Total Medical Medicare Payment Amount | 14369.87 |
| Total Medical Medicare Standardized Payment Amount | 14729.66 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 18 |
| Number Of Beneficiaries Age 65 to 74 | 33 |
| Number Of Beneficiaries Age 75 to 84 | 24 |
| Number Of Beneficiaries Age Greater 84 | 13 |
| Number Of Female Beneficiaries | 63 |
| Number Of Male Beneficiaries | 25 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 70 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 18 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 20 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | 20 |
| Percent Of With Osteoporosis | 15 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 69 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9466 |