| National Provider Identifier [NPI]: | 1548415367 |
| Last Name Of The Provider | DEBARTOLO |
| First Name Of The Provider | DORE |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 18660 GRAPHIC DR |
| Street Address 2 Of The Provider | SUITE 100 |
| City Of The Provider | TINLEY PARK |
| Zip Code Of The Provider | 604776257 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Sports Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 41 |
| Number Of Services | 4780 |
| Number Of Medicare Beneficiaries | 192 |
| Total Submitted Charge Amount | 320509.44 |
| Total Medicare Allowed Amount | 121042.02 |
| Total Medicare Payment Amount | 93296.93 |
| Total Medicare Standardized Payment Amount | 85570.99 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 3662 |
| Number Of Medicare Beneficiaries With Drug Services | 83 |
| Total Drug Submitted ChargeAmount | 95358 |
| Total Drug Medicare AllowedAmount | 42612.66 |
| Total Drug Medicare PaymentAmount | 33398.71 |
| Total Drug Medicare Standardized Payment Amount | 33398.71 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 38 |
| Number Of Medical Services | 1118 |
| Number Of Medicare Beneficiaries With Medical Services | 192 |
| Total Medical Submitted Charge Amount | 225151.44 |
| Total Medical Medicare Allowed Amount | 78429.36 |
| Total Medical Medicare Payment Amount | 59898.22 |
| Total Medical Medicare Standardized Payment Amount | 52172.28 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 45 |
| Number Of Beneficiaries Age 65 to 74 | 92 |
| Number Of Beneficiaries Age 75 to 84 | 39 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 138 |
| Number Of Male Beneficiaries | 54 |
| Number Of Non Hispanic White Beneficiaries | 44 |
| Number Of Black or African American Beneficiaries | 130 |
| 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 | 124 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 68 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 9 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 54 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1512 |