| National Provider Identifier [NPI]: | 1063433050 |
| Last Name Of The Provider | HIDDEN |
| First Name Of The Provider | GLEN |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 50 E HOSPITAL ST |
| Street Address 2 Of The Provider | SUITE 4 |
| City Of The Provider | MANNING |
| Zip Code Of The Provider | 291023149 |
| State Code Of The Provider | SC |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Psychiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 58 |
| Number Of Services | 781 |
| Number Of Medicare Beneficiaries | 162 |
| Total Submitted Charge Amount | 24372.6 |
| Total Medicare Allowed Amount | 23185.21 |
| Total Medicare Payment Amount | 14822.12 |
| Total Medicare Standardized Payment Amount | 15833.67 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 13 |
| Number Of Drug Services | 381 |
| Number Of Medicare Beneficiaries With Drug Services | 47 |
| Total Drug Submitted ChargeAmount | 849.29 |
| Total Drug Medicare AllowedAmount | 483.77 |
| Total Drug Medicare PaymentAmount | 345.55 |
| Total Drug Medicare Standardized Payment Amount | 345.55 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 45 |
| Number Of Medical Services | 400 |
| Number Of Medicare Beneficiaries With Medical Services | 162 |
| Total Medical Submitted Charge Amount | 23523.31 |
| Total Medical Medicare Allowed Amount | 22701.44 |
| Total Medical Medicare Payment Amount | 14476.57 |
| Total Medical Medicare Standardized Payment Amount | 15488.12 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 14 |
| Number Of Beneficiaries Age 65 to 74 | 87 |
| Number Of Beneficiaries Age 75 to 84 | 50 |
| Number Of Beneficiaries Age Greater 84 | 11 |
| Number Of Female Beneficiaries | 99 |
| Number Of Male Beneficiaries | 63 |
| Number Of Non Hispanic White Beneficiaries | 137 |
| Number Of Black or African American Beneficiaries | 12 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 150 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 12 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 20 |
| Percent Of With Hyperlipidemia | 51 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8485 |