| National Provider Identifier [NPI]: | 1619176021 |
| Last Name Of The Provider | SMITH |
| First Name Of The Provider | TRAVIS |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1611 W HARRISON ST |
| Street Address 2 Of The Provider | STE 400 |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606123841 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 14 |
| Number Of Services | 67 |
| Number Of Medicare Beneficiaries | 20 |
| Total Submitted Charge Amount | 30798.04 |
| Total Medicare Allowed Amount | 6861.27 |
| Total Medicare Payment Amount | 5166.68 |
| Total Medicare Standardized Payment Amount | 5275.14 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 19 |
| Number Of Medicare Beneficiaries With Drug Services | 15 |
| Total Drug Submitted ChargeAmount | 9373 |
| Total Drug Medicare AllowedAmount | 4143.71 |
| Total Drug Medicare PaymentAmount | 3133.43 |
| Total Drug Medicare Standardized Payment Amount | 3133.43 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 10 |
| Number Of Medical Services | 48 |
| Number Of Medicare Beneficiaries With Medical Services | 20 |
| Total Medical Submitted Charge Amount | 21425.04 |
| Total Medical Medicare Allowed Amount | 2717.56 |
| Total Medical Medicare Payment Amount | 2033.25 |
| Total Medical Medicare Standardized Payment Amount | 2141.71 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | |
| Number Of Male Beneficiaries | |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 0 |
| Percent Of With Alzheimers Disease or Dementia | 0 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | |
| Percent Of With Hypertension | |
| Percent Of With Ischemic Heart Disease | |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 65 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 0.8915 |