| National Provider Identifier [NPI]: | 1619957164 |
| Last Name Of The Provider | HOLTSCLAW |
| First Name Of The Provider | LISA |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4666 W JEFFERSON BLVD |
| Street Address 2 Of The Provider | SUITE 140 |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468046892 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 39 |
| Number Of Services | 569 |
| Number Of Medicare Beneficiaries | 173 |
| Total Submitted Charge Amount | 70743 |
| Total Medicare Allowed Amount | 38379.35 |
| Total Medicare Payment Amount | 25467.98 |
| Total Medicare Standardized Payment Amount | 27754.48 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 52 |
| Number Of Medicare Beneficiaries With Drug Services | 39 |
| Total Drug Submitted ChargeAmount | 3799 |
| Total Drug Medicare AllowedAmount | 1464.88 |
| Total Drug Medicare PaymentAmount | 1432.67 |
| Total Drug Medicare Standardized Payment Amount | 1432.67 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 517 |
| Number Of Medicare Beneficiaries With Medical Services | 173 |
| Total Medical Submitted Charge Amount | 66944 |
| Total Medical Medicare Allowed Amount | 36914.47 |
| Total Medical Medicare Payment Amount | 24035.31 |
| Total Medical Medicare Standardized Payment Amount | 26321.81 |
| Average Age Of Beneficiaries | 62 |
| Number Of Beneficiaries Age Less65 | 73 |
| Number Of Beneficiaries Age 65 to 74 | 73 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 112 |
| Number Of Male Beneficiaries | 61 |
| Number Of Non Hispanic White Beneficiaries | 146 |
| 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 | 100 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 73 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 22 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9072 |