| National Provider Identifier [NPI]: | 1841274255 |
| Last Name Of The Provider | PETERSEN |
| First Name Of The Provider | DALE |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2001 BLAISDELL AVE |
| Street Address 2 Of The Provider | PARK NICOLLET CLINIC MINNEAPOLIS |
| City Of The Provider | MINNEAPOLIS |
| Zip Code Of The Provider | 554042414 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 38 |
| Number Of Services | 1032 |
| Number Of Medicare Beneficiaries | 260 |
| Total Submitted Charge Amount | 111940.5 |
| Total Medicare Allowed Amount | 50583.46 |
| Total Medicare Payment Amount | 37455.6 |
| Total Medicare Standardized Payment Amount | 38659.7 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 193 |
| Number Of Medicare Beneficiaries With Drug Services | 66 |
| Total Drug Submitted ChargeAmount | 6894 |
| Total Drug Medicare AllowedAmount | 4082.04 |
| Total Drug Medicare PaymentAmount | 3834.71 |
| Total Drug Medicare Standardized Payment Amount | 3834.71 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 32 |
| Number Of Medical Services | 839 |
| Number Of Medicare Beneficiaries With Medical Services | 259 |
| Total Medical Submitted Charge Amount | 105046.5 |
| Total Medical Medicare Allowed Amount | 46501.42 |
| Total Medical Medicare Payment Amount | 33620.89 |
| Total Medical Medicare Standardized Payment Amount | 34824.99 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 99 |
| Number Of Beneficiaries Age 65 to 74 | 73 |
| Number Of Beneficiaries Age 75 to 84 | 50 |
| Number Of Beneficiaries Age Greater 84 | 38 |
| Number Of Female Beneficiaries | 129 |
| Number Of Male Beneficiaries | 131 |
| Number Of Non Hispanic White Beneficiaries | 203 |
| Number Of Black or African American Beneficiaries | 44 |
| 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 | 146 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 114 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 35 |
| Percent Of With Hypertension | 45 |
| Percent Of With Ischemic Heart Disease | 20 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 28 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.2956 |