| National Provider Identifier [NPI]: | 1275687766 |
| Last Name Of The Provider | MATHISEN |
| First Name Of The Provider | JAN |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1940 ELMER J BISSELL RD |
| Street Address 2 Of The Provider | SUITE C |
| City Of The Provider | BIRMINGHAM |
| Zip Code Of The Provider | 352432941 |
| State Code Of The Provider | AL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pediatric Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 6 |
| Number Of Services | 53 |
| Number Of Medicare Beneficiaries | 46 |
| Total Submitted Charge Amount | 7150 |
| Total Medicare Allowed Amount | 3939.02 |
| Total Medicare Payment Amount | 1983.04 |
| Total Medicare Standardized Payment Amount | 2373.23 |
| 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 | 6 |
| Number Of Medical Services | 53 |
| Number Of Medicare Beneficiaries With Medical Services | 46 |
| Total Medical Submitted Charge Amount | 7150 |
| Total Medical Medicare Allowed Amount | 3939.02 |
| Total Medical Medicare Payment Amount | 1983.04 |
| Total Medical Medicare Standardized Payment Amount | 2373.23 |
| Average Age Of Beneficiaries | 29 |
| Number Of Beneficiaries Age Less65 | 46 |
| Number Of Beneficiaries Age 65 to 74 | 0 |
| Number Of Beneficiaries Age 75 to 84 | 0 |
| Number Of Beneficiaries Age Greater 84 | 0 |
| Number Of Female Beneficiaries | 12 |
| Number Of Male Beneficiaries | 34 |
| Number Of Non Hispanic White Beneficiaries | 35 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 0 |
| Percent Of With Alzheimers Disease or Dementia | 0 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 0 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | 0 |
| Percent Of With Depression | |
| Percent Of With Diabetes | 0 |
| Percent Of With Hyperlipidemia | |
| Percent Of With Hypertension | |
| Percent Of With Ischemic Heart Disease | 0 |
| Percent Of With Osteoporosis | 0 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 0.9053 |