| National Provider Identifier [NPI]: | 1417924028 |
| Last Name Of The Provider | LACK |
| First Name Of The Provider | KEVIN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | P.A.-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3675 J DEWEY GRAY CIRCLE |
| Street Address 2 Of The Provider | SUITE 300 |
| City Of The Provider | AUGUSTA |
| Zip Code Of The Provider | 309091868 |
| 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 | 22 |
| Number Of Services | 888 |
| Number Of Medicare Beneficiaries | 98 |
| Total Submitted Charge Amount | 166239 |
| Total Medicare Allowed Amount | 12340.89 |
| Total Medicare Payment Amount | 9646.79 |
| Total Medicare Standardized Payment Amount | 9449.14 |
| 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 | 22 |
| Number Of Medical Services | 888 |
| Number Of Medicare Beneficiaries With Medical Services | 98 |
| Total Medical Submitted Charge Amount | 166239 |
| Total Medical Medicare Allowed Amount | 12340.89 |
| Total Medical Medicare Payment Amount | 9646.79 |
| Total Medical Medicare Standardized Payment Amount | 9449.14 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 31 |
| Number Of Beneficiaries Age 65 to 74 | 37 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 46 |
| Number Of Male Beneficiaries | 52 |
| Number Of Non Hispanic White Beneficiaries | 59 |
| 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 | 63 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 35 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 21 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 28 |
| Percent Of With Chronic Kidney Disease | 41 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 37 |
| Percent Of With Diabetes | 50 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 42 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 11 |
| Average HCC Risk Score Of Beneficiaries | 1.8173 |