| National Provider Identifier [NPI]: | 1205839362 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | IVAN |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 210 WESTSIDE DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | DOTHAN |
| Zip Code Of The Provider | 363031928 |
| State Code Of The Provider | AL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 127 |
| Number Of Services | 10974.3 |
| Number Of Medicare Beneficiaries | 780 |
| Total Submitted Charge Amount | 572682 |
| Total Medicare Allowed Amount | 446804.96 |
| Total Medicare Payment Amount | 345352.72 |
| Total Medicare Standardized Payment Amount | 373391.13 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 1488.3 |
| Number Of Medicare Beneficiaries With Drug Services | 406 |
| Total Drug Submitted ChargeAmount | 31893 |
| Total Drug Medicare AllowedAmount | 19487.07 |
| Total Drug Medicare PaymentAmount | 18307.59 |
| Total Drug Medicare Standardized Payment Amount | 18307.59 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 115 |
| Number Of Medical Services | 9486 |
| Number Of Medicare Beneficiaries With Medical Services | 780 |
| Total Medical Submitted Charge Amount | 540789 |
| Total Medical Medicare Allowed Amount | 427317.89 |
| Total Medical Medicare Payment Amount | 327045.13 |
| Total Medical Medicare Standardized Payment Amount | 355083.54 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 58 |
| Number Of Beneficiaries Age 65 to 74 | 292 |
| Number Of Beneficiaries Age 75 to 84 | 285 |
| Number Of Beneficiaries Age Greater 84 | 145 |
| Number Of Female Beneficiaries | 459 |
| Number Of Male Beneficiaries | 321 |
| Number Of Non Hispanic White Beneficiaries | 698 |
| Number Of Black or African American Beneficiaries | 69 |
| 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 | 662 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 118 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 15 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 54 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 37 |
| Percent Of With Osteoporosis | 16 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 52 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.1965 |