| National Provider Identifier [NPI]: | 1588694004 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4615 EASTMAN AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MIDLAND |
| Zip Code Of The Provider | 486402610 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 74 |
| Number Of Services | 1344 |
| Number Of Medicare Beneficiaries | 429 |
| Total Submitted Charge Amount | 89159.5 |
| Total Medicare Allowed Amount | 74124.37 |
| Total Medicare Payment Amount | 47914.64 |
| Total Medicare Standardized Payment Amount | 51903.32 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 16 |
| Number Of Drug Services | 132 |
| Number Of Medicare Beneficiaries With Drug Services | 47 |
| Total Drug Submitted ChargeAmount | 1204.5 |
| Total Drug Medicare AllowedAmount | 807.41 |
| Total Drug Medicare PaymentAmount | 373.75 |
| Total Drug Medicare Standardized Payment Amount | 373.75 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 58 |
| Number Of Medical Services | 1212 |
| Number Of Medicare Beneficiaries With Medical Services | 429 |
| Total Medical Submitted Charge Amount | 87955 |
| Total Medical Medicare Allowed Amount | 73316.96 |
| Total Medical Medicare Payment Amount | 47540.89 |
| Total Medical Medicare Standardized Payment Amount | 51529.57 |
| Average Age Of Beneficiaries | 62 |
| Number Of Beneficiaries Age Less65 | 208 |
| Number Of Beneficiaries Age 65 to 74 | 126 |
| Number Of Beneficiaries Age 75 to 84 | 63 |
| Number Of Beneficiaries Age Greater 84 | 32 |
| Number Of Female Beneficiaries | 238 |
| Number Of Male Beneficiaries | 191 |
| Number Of Non Hispanic White Beneficiaries | 399 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 13 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 225 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 204 |
| Percent Of With Atrial Fibrillation | 4 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 5 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 10 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0209 |