| National Provider Identifier [NPI]: | 1639104458 |
| Last Name Of The Provider | FORMAN |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | DPM |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 170 STATE ROUTE 31 |
| Street Address 2 Of The Provider | |
| City Of The Provider | FLEMINGTON |
| Zip Code Of The Provider | 088225756 |
| State Code Of The Provider | NJ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Podiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 19 |
| Number Of Services | 4225 |
| Number Of Medicare Beneficiaries | 1024 |
| Total Submitted Charge Amount | 227192.48 |
| Total Medicare Allowed Amount | 205127.4 |
| Total Medicare Payment Amount | 141598.56 |
| Total Medicare Standardized Payment Amount | 126281.52 |
| 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 | 19 |
| Number Of Medical Services | 4225 |
| Number Of Medicare Beneficiaries With Medical Services | 1024 |
| Total Medical Submitted Charge Amount | 227192.48 |
| Total Medical Medicare Allowed Amount | 205127.4 |
| Total Medical Medicare Payment Amount | 141598.56 |
| Total Medical Medicare Standardized Payment Amount | 126281.52 |
| Average Age Of Beneficiaries | 80 |
| Number Of Beneficiaries Age Less65 | 51 |
| Number Of Beneficiaries Age 65 to 74 | 266 |
| Number Of Beneficiaries Age 75 to 84 | 325 |
| Number Of Beneficiaries Age Greater 84 | 382 |
| Number Of Female Beneficiaries | 671 |
| Number Of Male Beneficiaries | 353 |
| Number Of Non Hispanic White Beneficiaries | 988 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 14 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 11 |
| Number Of Beneficiaries With Medicare Only Entitlement | 939 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 85 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 18 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 22 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 40 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 43 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.3441 |