| National Provider Identifier [NPI]: | 1215948351 |
| Last Name Of The Provider | MOCK |
| First Name Of The Provider | DALE |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 10798 W. OVERLAND RD |
| Street Address 2 Of The Provider | BOISE FAMILY MEDICINE CENTER |
| City Of The Provider | BOISE |
| Zip Code Of The Provider | 837091329 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 59 |
| Number Of Services | 2191 |
| Number Of Medicare Beneficiaries | 222 |
| Total Submitted Charge Amount | 87715.18 |
| Total Medicare Allowed Amount | 75204.29 |
| Total Medicare Payment Amount | 55064.33 |
| Total Medicare Standardized Payment Amount | 59861.01 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 143 |
| Number Of Medicare Beneficiaries With Drug Services | 87 |
| Total Drug Submitted ChargeAmount | 1330.82 |
| Total Drug Medicare AllowedAmount | 1195.65 |
| Total Drug Medicare PaymentAmount | 1137.22 |
| Total Drug Medicare Standardized Payment Amount | 1137.22 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 51 |
| Number Of Medical Services | 2048 |
| Number Of Medicare Beneficiaries With Medical Services | 222 |
| Total Medical Submitted Charge Amount | 86384.36 |
| Total Medical Medicare Allowed Amount | 74008.64 |
| Total Medical Medicare Payment Amount | 53927.11 |
| Total Medical Medicare Standardized Payment Amount | 58723.79 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 15 |
| Number Of Beneficiaries Age 65 to 74 | 117 |
| Number Of Beneficiaries Age 75 to 84 | 64 |
| Number Of Beneficiaries Age Greater 84 | 26 |
| Number Of Female Beneficiaries | 109 |
| Number Of Male Beneficiaries | 113 |
| 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 | 206 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 16 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 6 |
| Percent Of With Depression | 12 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 45 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 22 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 28 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8532 |