| National Provider Identifier [NPI]: | 1730149816 |
| Last Name Of The Provider | SMITH |
| First Name Of The Provider | TERESA |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1234 E DUPONT RD |
| Street Address 2 Of The Provider | SUITE 1 |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468251545 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 30 |
| Number Of Services | 822 |
| Number Of Medicare Beneficiaries | 183 |
| Total Submitted Charge Amount | 90053 |
| Total Medicare Allowed Amount | 46852.77 |
| Total Medicare Payment Amount | 31632.37 |
| Total Medicare Standardized Payment Amount | 33586.69 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 137 |
| Number Of Medicare Beneficiaries With Drug Services | 98 |
| Total Drug Submitted ChargeAmount | 8261 |
| Total Drug Medicare AllowedAmount | 3119.93 |
| Total Drug Medicare PaymentAmount | 3045.33 |
| Total Drug Medicare Standardized Payment Amount | 3045.33 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 26 |
| Number Of Medical Services | 685 |
| Number Of Medicare Beneficiaries With Medical Services | 183 |
| Total Medical Submitted Charge Amount | 81792 |
| Total Medical Medicare Allowed Amount | 43732.84 |
| Total Medical Medicare Payment Amount | 28587.04 |
| Total Medical Medicare Standardized Payment Amount | 30541.36 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 22 |
| Number Of Beneficiaries Age 65 to 74 | 89 |
| Number Of Beneficiaries Age 75 to 84 | 55 |
| Number Of Beneficiaries Age Greater 84 | 17 |
| Number Of Female Beneficiaries | 121 |
| Number Of Male Beneficiaries | 62 |
| 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 | 167 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 16 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 10 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 8 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 66 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 0.8397 |