| National Provider Identifier [NPI]: | 1396907705 |
| Last Name Of The Provider | KELLUM |
| First Name Of The Provider | ETHAN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1827 HARRISON AVE |
| Street Address 2 Of The Provider | BUILDING 1 |
| City Of The Provider | PANAMA CITY |
| Zip Code Of The Provider | 324057605 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Orthopedic Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 28 |
| Number Of Services | 154 |
| Number Of Medicare Beneficiaries | 56 |
| Total Submitted Charge Amount | 41894.73 |
| Total Medicare Allowed Amount | 17417.84 |
| Total Medicare Payment Amount | 12752.41 |
| Total Medicare Standardized Payment Amount | 14282.61 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 36 |
| Number Of Medicare Beneficiaries With Drug Services | 18 |
| Total Drug Submitted ChargeAmount | 4696 |
| Total Drug Medicare AllowedAmount | 1778.71 |
| Total Drug Medicare PaymentAmount | 1390.84 |
| Total Drug Medicare Standardized Payment Amount | 1390.84 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 23 |
| Number Of Medical Services | 118 |
| Number Of Medicare Beneficiaries With Medical Services | 56 |
| Total Medical Submitted Charge Amount | 37198.73 |
| Total Medical Medicare Allowed Amount | 15639.13 |
| Total Medical Medicare Payment Amount | 11361.57 |
| Total Medical Medicare Standardized Payment Amount | 12891.77 |
| Average Age Of Beneficiaries | 63 |
| Number Of Beneficiaries Age Less65 | 28 |
| Number Of Beneficiaries Age 65 to 74 | 16 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 34 |
| Number Of Male Beneficiaries | 22 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | 31 |
| 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 | 28 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 28 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 21 |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 45 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 64 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.5095 |