| National Provider Identifier [NPI]: | 1417060526 |
| Last Name Of The Provider | WIZIECKI |
| First Name Of The Provider | LARA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | DO |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4321 FIR ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | EAST CHICAGO |
| Zip Code Of The Provider | 463123049 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 43 |
| Number Of Services | 850 |
| Number Of Medicare Beneficiaries | 484 |
| Total Submitted Charge Amount | 107722 |
| Total Medicare Allowed Amount | 49263.67 |
| Total Medicare Payment Amount | 35062.49 |
| Total Medicare Standardized Payment Amount | 37550.5 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 170 |
| Number Of Medicare Beneficiaries With Drug Services | 54 |
| Total Drug Submitted ChargeAmount | 917 |
| Total Drug Medicare AllowedAmount | 231.23 |
| Total Drug Medicare PaymentAmount | 180.14 |
| Total Drug Medicare Standardized Payment Amount | 180.14 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 33 |
| Number Of Medical Services | 680 |
| Number Of Medicare Beneficiaries With Medical Services | 484 |
| Total Medical Submitted Charge Amount | 106805 |
| Total Medical Medicare Allowed Amount | 49032.44 |
| Total Medical Medicare Payment Amount | 34882.35 |
| Total Medical Medicare Standardized Payment Amount | 37370.36 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 46 |
| Number Of Beneficiaries Age 65 to 74 | 225 |
| Number Of Beneficiaries Age 75 to 84 | 151 |
| Number Of Beneficiaries Age Greater 84 | 62 |
| Number Of Female Beneficiaries | 304 |
| Number Of Male Beneficiaries | 180 |
| Number Of Non Hispanic White Beneficiaries | 457 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 15 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 464 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 20 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.0563 |