| National Provider Identifier [NPI]: | 1568449288 |
| Last Name Of The Provider | FACKENTHALL |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1312 E ISAACS AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | WALLA WALLA |
| Zip Code Of The Provider | 993622152 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | General Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 22 |
| Number Of Services | 915 |
| Number Of Medicare Beneficiaries | 116 |
| Total Submitted Charge Amount | 78313 |
| Total Medicare Allowed Amount | 73960.18 |
| Total Medicare Payment Amount | 51535.16 |
| Total Medicare Standardized Payment Amount | 54749.86 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 32 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 239 |
| Total Drug Medicare AllowedAmount | 183.59 |
| Total Drug Medicare PaymentAmount | 138.22 |
| Total Drug Medicare Standardized Payment Amount | 138.22 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 883 |
| Number Of Medicare Beneficiaries With Medical Services | 116 |
| Total Medical Submitted Charge Amount | 78074 |
| Total Medical Medicare Allowed Amount | 73776.59 |
| Total Medical Medicare Payment Amount | 51396.94 |
| Total Medical Medicare Standardized Payment Amount | 54611.64 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 11 |
| Number Of Beneficiaries Age 65 to 74 | 38 |
| Number Of Beneficiaries Age 75 to 84 | 50 |
| Number Of Beneficiaries Age Greater 84 | 17 |
| Number Of Female Beneficiaries | 63 |
| Number Of Male Beneficiaries | 53 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 101 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 15 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 9 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 54 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 47 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1862 |