| National Provider Identifier [NPI]: | 1548263130 |
| Last Name Of The Provider | WIACEK |
| First Name Of The Provider | JAN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3204 N OAK PARK AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606344640 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 58 |
| Number Of Services | 4215 |
| Number Of Medicare Beneficiaries | 453 |
| Total Submitted Charge Amount | 712731 |
| Total Medicare Allowed Amount | 298039.3 |
| Total Medicare Payment Amount | 216473.35 |
| Total Medicare Standardized Payment Amount | 202953.55 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 108 |
| Number Of Medicare Beneficiaries With Drug Services | 70 |
| Total Drug Submitted ChargeAmount | 2515 |
| Total Drug Medicare AllowedAmount | 1010.02 |
| Total Drug Medicare PaymentAmount | 976.93 |
| Total Drug Medicare Standardized Payment Amount | 976.93 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 51 |
| Number Of Medical Services | 4107 |
| Number Of Medicare Beneficiaries With Medical Services | 453 |
| Total Medical Submitted Charge Amount | 710216 |
| Total Medical Medicare Allowed Amount | 297029.28 |
| Total Medical Medicare Payment Amount | 215496.42 |
| Total Medical Medicare Standardized Payment Amount | 201976.62 |
| Average Age Of Beneficiaries | 78 |
| Number Of Beneficiaries Age Less65 | 42 |
| Number Of Beneficiaries Age 65 to 74 | 118 |
| Number Of Beneficiaries Age 75 to 84 | 157 |
| Number Of Beneficiaries Age Greater 84 | 136 |
| Number Of Female Beneficiaries | 292 |
| Number Of Male Beneficiaries | 161 |
| Number Of Non Hispanic White Beneficiaries | 406 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 285 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 168 |
| Percent Of With Atrial Fibrillation | 16 |
| Percent Of With Alzheimers Disease or Dementia | 26 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 51 |
| Percent Of With Chronic Kidney Disease | 30 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 21 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 46 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.4931 |