| National Provider Identifier [NPI]: | 1336173574 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | HEATHER |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 613 STEPHENSON AVE |
| Street Address 2 Of The Provider | EXECUTIVE PARK SUITE 208 |
| City Of The Provider | SAVANNAH |
| Zip Code Of The Provider | 314055986 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Urology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 1192 |
| Number Of Medicare Beneficiaries | 243 |
| Total Submitted Charge Amount | 141985 |
| Total Medicare Allowed Amount | 60700.77 |
| Total Medicare Payment Amount | 46198.17 |
| Total Medicare Standardized Payment Amount | 49689.09 |
| Drug Suppress Indicator | * |
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| Number Of Medicare Beneficiaries With Drug Services | |
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| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
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| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
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| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 32 |
| Number Of Beneficiaries Age 65 to 74 | 100 |
| Number Of Beneficiaries Age 75 to 84 | 74 |
| Number Of Beneficiaries Age Greater 84 | 37 |
| Number Of Female Beneficiaries | 134 |
| Number Of Male Beneficiaries | 109 |
| Number Of Non Hispanic White Beneficiaries | 178 |
| Number Of Black or African American Beneficiaries | 50 |
| 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 | 217 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 26 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 24 |
| Percent Of With Diabetes | 40 |
| Percent Of With Hyperlipidemia | 69 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.2757 |