| National Provider Identifier [NPI]: | 1528006491 |
| Last Name Of The Provider | WALL |
| First Name Of The Provider | JON |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4624 HOLLADAY BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841175206 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 75 |
| Number Of Services | 1447 |
| Number Of Medicare Beneficiaries | 151 |
| Total Submitted Charge Amount | 89981 |
| Total Medicare Allowed Amount | 60436.41 |
| Total Medicare Payment Amount | 47806.66 |
| Total Medicare Standardized Payment Amount | 49597.25 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 155 |
| Number Of Medicare Beneficiaries With Drug Services | 80 |
| Total Drug Submitted ChargeAmount | 10490 |
| Total Drug Medicare AllowedAmount | 8597.59 |
| Total Drug Medicare PaymentAmount | 8408.39 |
| Total Drug Medicare Standardized Payment Amount | 8408.39 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 65 |
| Number Of Medical Services | 1292 |
| Number Of Medicare Beneficiaries With Medical Services | 151 |
| Total Medical Submitted Charge Amount | 79491 |
| Total Medical Medicare Allowed Amount | 51838.82 |
| Total Medical Medicare Payment Amount | 39398.27 |
| Total Medical Medicare Standardized Payment Amount | 41188.86 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 68 |
| Number Of Beneficiaries Age 75 to 84 | 55 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 83 |
| Number Of Male Beneficiaries | 68 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 8 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 8 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 56 |
| Percent Of With Ischemic Heart Disease | 20 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8244 |