| National Provider Identifier [NPI]: | 1598734097 |
| Last Name Of The Provider | WIETSMA |
| First Name Of The Provider | ANN |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | AU.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 45 N MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | KILMARNOCK |
| Zip Code Of The Provider | 224828501 |
| State Code Of The Provider | VA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Audiologist (billing independently) |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 6 |
| Number Of Services | 375 |
| Number Of Medicare Beneficiaries | 218 |
| Total Submitted Charge Amount | 28050.25 |
| Total Medicare Allowed Amount | 10729.23 |
| Total Medicare Payment Amount | 7082.39 |
| Total Medicare Standardized Payment Amount | 7224.3 |
| 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 | 6 |
| Number Of Medical Services | 375 |
| Number Of Medicare Beneficiaries With Medical Services | 218 |
| Total Medical Submitted Charge Amount | 28050.25 |
| Total Medical Medicare Allowed Amount | 10729.23 |
| Total Medical Medicare Payment Amount | 7082.39 |
| Total Medical Medicare Standardized Payment Amount | 7224.3 |
| Average Age Of Beneficiaries | 77 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 82 |
| Number Of Beneficiaries Age 75 to 84 | 84 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 117 |
| Number Of Male Beneficiaries | 101 |
| Number Of Non Hispanic White Beneficiaries | 191 |
| 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 | 201 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 17 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 11 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 9 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 0.9784 |