| National Provider Identifier [NPI]: | 1932210069 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | PRISCILLA |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 233 NE 102ND AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | PORTLAND |
| Zip Code Of The Provider | 97220 |
| State Code Of The Provider | OR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 96 |
| Number Of Services | 4905 |
| Number Of Medicare Beneficiaries | 815 |
| Total Submitted Charge Amount | 422620.25 |
| Total Medicare Allowed Amount | 141448.97 |
| Total Medicare Payment Amount | 119051.35 |
| Total Medicare Standardized Payment Amount | 115748.59 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 3420 |
| Number Of Medicare Beneficiaries With Drug Services | 43 |
| Total Drug Submitted ChargeAmount | 3062.25 |
| Total Drug Medicare AllowedAmount | 1030.86 |
| Total Drug Medicare PaymentAmount | 762.49 |
| Total Drug Medicare Standardized Payment Amount | 762.49 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 94 |
| Number Of Medical Services | 1485 |
| Number Of Medicare Beneficiaries With Medical Services | 814 |
| Total Medical Submitted Charge Amount | 419558 |
| Total Medical Medicare Allowed Amount | 140418.11 |
| Total Medical Medicare Payment Amount | 118288.86 |
| Total Medical Medicare Standardized Payment Amount | 114986.1 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 112 |
| Number Of Beneficiaries Age 65 to 74 | 437 |
| Number Of Beneficiaries Age 75 to 84 | 206 |
| Number Of Beneficiaries Age Greater 84 | 60 |
| Number Of Female Beneficiaries | 716 |
| Number Of Male Beneficiaries | 99 |
| Number Of Non Hispanic White Beneficiaries | 675 |
| Number Of Black or African American Beneficiaries | 28 |
| Number Of AsianPacific Islander Beneficiaries | 59 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 25 |
| Number Of Beneficiaries With Medicare Only Entitlement | 632 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 183 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 9 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 42 |
| Percent Of With Hypertension | 49 |
| Percent Of With Ischemic Heart Disease | 15 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 0.8995 |