| National Provider Identifier [NPI]: | 1255309332 |
| Last Name Of The Provider | PORTALATIN |
| First Name Of The Provider | MANUEL |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 9090 REGENCY SQUARE BLVD |
| Street Address 2 Of The Provider | CREDENTIALING DEPARTMENT |
| City Of The Provider | JACKSONVILLE |
| Zip Code Of The Provider | 322118119 |
| 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 | 84 |
| Number Of Services | 2313 |
| Number Of Medicare Beneficiaries | 310 |
| Total Submitted Charge Amount | 171332 |
| Total Medicare Allowed Amount | 97521 |
| Total Medicare Payment Amount | 71896.61 |
| Total Medicare Standardized Payment Amount | 73395.86 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 21 |
| Number Of Drug Services | 637 |
| Number Of Medicare Beneficiaries With Drug Services | 152 |
| Total Drug Submitted ChargeAmount | 21595 |
| Total Drug Medicare AllowedAmount | 12964.94 |
| Total Drug Medicare PaymentAmount | 11426.09 |
| Total Drug Medicare Standardized Payment Amount | 11426.09 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 63 |
| Number Of Medical Services | 1676 |
| Number Of Medicare Beneficiaries With Medical Services | 309 |
| Total Medical Submitted Charge Amount | 149737 |
| Total Medical Medicare Allowed Amount | 84556.06 |
| Total Medical Medicare Payment Amount | 60470.52 |
| Total Medical Medicare Standardized Payment Amount | 61969.77 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 33 |
| Number Of Beneficiaries Age 65 to 74 | 169 |
| Number Of Beneficiaries Age 75 to 84 | 93 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 156 |
| Number Of Male Beneficiaries | 154 |
| Number Of Non Hispanic White Beneficiaries | 221 |
| Number Of Black or African American Beneficiaries | 42 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 33 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 293 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 17 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 5 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 47 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | 4 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.106 |