| National Provider Identifier [NPI]: | 1710173968 |
| Last Name Of The Provider | DIVINE |
| First Name Of The Provider | JONATHAN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 9560 CROSSHILL BLVD STE 110 |
| Street Address 2 Of The Provider | |
| City Of The Provider | JACKSONVILLE |
| Zip Code Of The Provider | 322225827 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 44 |
| Number Of Services | 1012 |
| Number Of Medicare Beneficiaries | 224 |
| Total Submitted Charge Amount | 238770.41 |
| Total Medicare Allowed Amount | 79675.42 |
| Total Medicare Payment Amount | 55645.26 |
| Total Medicare Standardized Payment Amount | 56684.72 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 83 |
| Number Of Medicare Beneficiaries With Drug Services | 52 |
| Total Drug Submitted ChargeAmount | 5846.65 |
| Total Drug Medicare AllowedAmount | 2197.76 |
| Total Drug Medicare PaymentAmount | 2135.3 |
| Total Drug Medicare Standardized Payment Amount | 2135.3 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 37 |
| Number Of Medical Services | 929 |
| Number Of Medicare Beneficiaries With Medical Services | 224 |
| Total Medical Submitted Charge Amount | 232923.76 |
| Total Medical Medicare Allowed Amount | 77477.66 |
| Total Medical Medicare Payment Amount | 53509.96 |
| Total Medical Medicare Standardized Payment Amount | 54549.42 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 28 |
| Number Of Beneficiaries Age 65 to 74 | 131 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 13 |
| Number Of Female Beneficiaries | 117 |
| Number Of Male Beneficiaries | 107 |
| Number Of Non Hispanic White Beneficiaries | 192 |
| Number Of Black or African American Beneficiaries | 16 |
| 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 | 201 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 23 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0217 |