| National Provider Identifier [NPI]: | 1083608053 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | DOUGLAS |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2300 MANCHESTER EXPY |
| Street Address 2 Of The Provider | STE A001 |
| City Of The Provider | COLUMBUS |
| Zip Code Of The Provider | 319046802 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 11 |
| Number Of Services | 3323 |
| Number Of Medicare Beneficiaries | 1448 |
| Total Submitted Charge Amount | 214353.25 |
| Total Medicare Allowed Amount | 67418.54 |
| Total Medicare Payment Amount | 59004.77 |
| Total Medicare Standardized Payment Amount | 60907.45 |
| 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 | 3323 |
| Number Of Medicare Beneficiaries With Medical Services | 1448 |
| Total Medical Submitted Charge Amount | 214353.25 |
| Total Medical Medicare Allowed Amount | 67418.54 |
| Total Medical Medicare Payment Amount | 59004.77 |
| Total Medical Medicare Standardized Payment Amount | 60907.45 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 118 |
| Number Of Beneficiaries Age 65 to 74 | 764 |
| Number Of Beneficiaries Age 75 to 84 | 452 |
| Number Of Beneficiaries Age Greater 84 | 114 |
| Number Of Female Beneficiaries | |
| Number Of Male Beneficiaries | |
| Number Of Non Hispanic White Beneficiaries | 1171 |
| Number Of Black or African American Beneficiaries | 227 |
| Number Of AsianPacific Islander Beneficiaries | 11 |
| Number Of Hispanic Beneficiaries | 25 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 14 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1314 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 134 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 5 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 70 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 16 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 1 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 0.9034 |