| National Provider Identifier [NPI]: | 1720394612 |
| Last Name Of The Provider | MANTILLA-ACEVEDO |
| First Name Of The Provider | JOSE |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | NP |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2200 WABASH AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | SPRINGFIELD |
| Zip Code Of The Provider | 627045352 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 26 |
| Number Of Services | 569 |
| Number Of Medicare Beneficiaries | 162 |
| Total Submitted Charge Amount | 19956.71 |
| Total Medicare Allowed Amount | 15386.36 |
| Total Medicare Payment Amount | 9749.03 |
| Total Medicare Standardized Payment Amount | 12389.92 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 23 |
| Number Of Medicare Beneficiaries With Drug Services | 13 |
| Total Drug Submitted ChargeAmount | 520.07 |
| Total Drug Medicare AllowedAmount | 486.17 |
| Total Drug Medicare PaymentAmount | 427.75 |
| Total Drug Medicare Standardized Payment Amount | 427.75 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 20 |
| Number Of Medical Services | 546 |
| Number Of Medicare Beneficiaries With Medical Services | 162 |
| Total Medical Submitted Charge Amount | 19436.64 |
| Total Medical Medicare Allowed Amount | 14900.19 |
| Total Medical Medicare Payment Amount | 9321.28 |
| Total Medical Medicare Standardized Payment Amount | 11962.17 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 19 |
| Number Of Beneficiaries Age 65 to 74 | 75 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 80 |
| Number Of Male Beneficiaries | 82 |
| 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 | 150 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 12 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| 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 | 12 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 54 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 21 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1 |