| National Provider Identifier [NPI]: | 1114239316 |
| Last Name Of The Provider | ELLIS |
| First Name Of The Provider | CHARLI |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 7808 CLODUS FIELDS DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | DALLAS |
| Zip Code Of The Provider | 752512206 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Psychiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 11 |
| Number Of Services | 325 |
| Number Of Medicare Beneficiaries | 174 |
| Total Submitted Charge Amount | 66608 |
| Total Medicare Allowed Amount | 30398.01 |
| Total Medicare Payment Amount | 23832.33 |
| Total Medicare Standardized Payment Amount | 23721.5 |
| 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 | 11 |
| Number Of Medical Services | 325 |
| Number Of Medicare Beneficiaries With Medical Services | 174 |
| Total Medical Submitted Charge Amount | 66608 |
| Total Medical Medicare Allowed Amount | 30398.01 |
| Total Medical Medicare Payment Amount | 23832.33 |
| Total Medical Medicare Standardized Payment Amount | 23721.5 |
| Average Age Of Beneficiaries | 48 |
| Number Of Beneficiaries Age Less65 | 151 |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 77 |
| Number Of Male Beneficiaries | 97 |
| Number Of Non Hispanic White Beneficiaries | 97 |
| Number Of Black or African American Beneficiaries | 63 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 51 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 123 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 22 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 69 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 33 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 20 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 75 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2317 |