| National Provider Identifier [NPI]: | 1770545238 |
| Last Name Of The Provider | SIVORAVONG |
| First Name Of The Provider | JON |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 855 MONTGOMERY |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WORTH |
| Zip Code Of The Provider | 761072553 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 803 |
| Number Of Medicare Beneficiaries | 204 |
| Total Submitted Charge Amount | 102800 |
| Total Medicare Allowed Amount | 52852.99 |
| Total Medicare Payment Amount | 36308.88 |
| Total Medicare Standardized Payment Amount | 37150.88 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 93 |
| Number Of Medicare Beneficiaries With Drug Services | 59 |
| Total Drug Submitted ChargeAmount | 4804 |
| Total Drug Medicare AllowedAmount | 2124.39 |
| Total Drug Medicare PaymentAmount | 2068.06 |
| Total Drug Medicare Standardized Payment Amount | 2068.06 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 33 |
| Number Of Medical Services | 710 |
| Number Of Medicare Beneficiaries With Medical Services | 204 |
| Total Medical Submitted Charge Amount | 97996 |
| Total Medical Medicare Allowed Amount | 50728.6 |
| Total Medical Medicare Payment Amount | 34240.82 |
| Total Medical Medicare Standardized Payment Amount | 35082.82 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 48 |
| Number Of Beneficiaries Age 65 to 74 | 78 |
| Number Of Beneficiaries Age 75 to 84 | 60 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 115 |
| Number Of Male Beneficiaries | 89 |
| Number Of Non Hispanic White Beneficiaries | 51 |
| Number Of Black or African American Beneficiaries | 94 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 34 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 116 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 88 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 22 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 23 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2554 |