| National Provider Identifier [NPI]: | 1194798975 |
| Last Name Of The Provider | JOSE |
| First Name Of The Provider | JOLLY |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 406 W. BLOOMINGDALE AVE |
| Street Address 2 Of The Provider | BLOOMINGDALE PRIMARY CARE CENTER PRIMARY CARE CENTER |
| City Of The Provider | BRANDON |
| Zip Code Of The Provider | 335117402 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 28 |
| Number Of Services | 167 |
| Number Of Medicare Beneficiaries | 40 |
| Total Submitted Charge Amount | 11072 |
| Total Medicare Allowed Amount | 7313.63 |
| Total Medicare Payment Amount | 4961.93 |
| Total Medicare Standardized Payment Amount | 4983.42 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 25 |
| Number Of Medicare Beneficiaries With Drug Services | 16 |
| Total Drug Submitted ChargeAmount | 419 |
| Total Drug Medicare AllowedAmount | 281.4 |
| Total Drug Medicare PaymentAmount | 271.07 |
| Total Drug Medicare Standardized Payment Amount | 271.07 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 20 |
| Number Of Medical Services | 142 |
| Number Of Medicare Beneficiaries With Medical Services | 40 |
| Total Medical Submitted Charge Amount | 10653 |
| Total Medical Medicare Allowed Amount | 7032.23 |
| Total Medical Medicare Payment Amount | 4690.86 |
| Total Medical Medicare Standardized Payment Amount | 4712.35 |
| Average Age Of Beneficiaries | 77 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 14 |
| Number Of Beneficiaries Age 75 to 84 | 15 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | |
| Number Of Male Beneficiaries | |
| Number Of Non Hispanic White Beneficiaries | 27 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| 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 | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 38 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 58 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 43 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.5529 |