| National Provider Identifier [NPI]: | 1720092307 |
| Last Name Of The Provider | BLACK |
| First Name Of The Provider | TIMOTHY |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | P.A.-C. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 709 MIDDLE CREEK RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | SEVIERVILLE |
| Zip Code Of The Provider | 378625047 |
| State Code Of The Provider | TN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 25 |
| Number Of Services | 354 |
| Number Of Medicare Beneficiaries | 289 |
| Total Submitted Charge Amount | 238401 |
| Total Medicare Allowed Amount | 30240.65 |
| Total Medicare Payment Amount | 23008.27 |
| Total Medicare Standardized Payment Amount | 28786.89 |
| 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 | 25 |
| Number Of Medical Services | 354 |
| Number Of Medicare Beneficiaries With Medical Services | 289 |
| Total Medical Submitted Charge Amount | 238401 |
| Total Medical Medicare Allowed Amount | 30240.65 |
| Total Medical Medicare Payment Amount | 23008.27 |
| Total Medical Medicare Standardized Payment Amount | 28786.89 |
| Average Age Of Beneficiaries | 58 |
| Number Of Beneficiaries Age Less65 | 183 |
| Number Of Beneficiaries Age 65 to 74 | 63 |
| Number Of Beneficiaries Age 75 to 84 | 27 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 148 |
| Number Of Male Beneficiaries | 141 |
| Number Of Non Hispanic White Beneficiaries | 253 |
| 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 | 130 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 159 |
| Percent Of With Atrial Fibrillation | 5 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 5 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 27 |
| Percent Of With Depression | 45 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 43 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 28 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 11 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.7783 |