| National Provider Identifier [NPI]: | 1962487538 |
| Last Name Of The Provider | LIDELL |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | M.M.SC. , PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1418 SCOTT BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | DECATUR |
| Zip Code Of The Provider | 300301424 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 59 |
| Number Of Services | 574 |
| Number Of Medicare Beneficiaries | 137 |
| Total Submitted Charge Amount | 34620 |
| Total Medicare Allowed Amount | 15702.42 |
| Total Medicare Payment Amount | 12255.5 |
| Total Medicare Standardized Payment Amount | 13823.79 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 188 |
| Number Of Medicare Beneficiaries With Drug Services | 36 |
| Total Drug Submitted ChargeAmount | 1164 |
| Total Drug Medicare AllowedAmount | 300.83 |
| Total Drug Medicare PaymentAmount | 274.28 |
| Total Drug Medicare Standardized Payment Amount | 274.28 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 47 |
| Number Of Medical Services | 386 |
| Number Of Medicare Beneficiaries With Medical Services | 137 |
| Total Medical Submitted Charge Amount | 33456 |
| Total Medical Medicare Allowed Amount | 15401.59 |
| Total Medical Medicare Payment Amount | 11981.22 |
| Total Medical Medicare Standardized Payment Amount | 13549.51 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 76 |
| Number Of Beneficiaries Age 75 to 84 | 29 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 86 |
| Number Of Male Beneficiaries | 51 |
| Number Of Non Hispanic White Beneficiaries | 119 |
| 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 | 116 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 21 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9907 |