| National Provider Identifier [NPI]: | 1386643310 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | ETHAN |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2015 JACKSON ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | ANDERSON |
| Zip Code Of The Provider | 460164337 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 35 |
| Number Of Services | 862 |
| Number Of Medicare Beneficiaries | 724 |
| Total Submitted Charge Amount | 535747 |
| Total Medicare Allowed Amount | 115821.25 |
| Total Medicare Payment Amount | 85512.94 |
| Total Medicare Standardized Payment Amount | 89372.84 |
| 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 | 35 |
| Number Of Medical Services | 862 |
| Number Of Medicare Beneficiaries With Medical Services | 724 |
| Total Medical Submitted Charge Amount | 535747 |
| Total Medical Medicare Allowed Amount | 115821.25 |
| Total Medical Medicare Payment Amount | 85512.94 |
| Total Medical Medicare Standardized Payment Amount | 89372.84 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 246 |
| Number Of Beneficiaries Age 65 to 74 | 204 |
| Number Of Beneficiaries Age 75 to 84 | 140 |
| Number Of Beneficiaries Age Greater 84 | 134 |
| Number Of Female Beneficiaries | 408 |
| Number Of Male Beneficiaries | 316 |
| Number Of Non Hispanic White Beneficiaries | 646 |
| Number Of Black or African American Beneficiaries | 67 |
| 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 | 415 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 309 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 20 |
| Percent Of With Asthma | 25 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 33 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 34 |
| Percent Of With Depression | 47 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 54 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 45 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 52 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 9 |
| Average HCC Risk Score Of Beneficiaries | 1.8484 |