| National Provider Identifier [NPI]: | 1902802192 |
| Last Name Of The Provider | DONNELLY |
| First Name Of The Provider | MARK |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1215 N BEAVER ST |
| Street Address 2 Of The Provider | STE 202 |
| City Of The Provider | FLAGSTAFF |
| Zip Code Of The Provider | 860013126 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | General Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 113 |
| Number Of Services | 426 |
| Number Of Medicare Beneficiaries | 252 |
| Total Submitted Charge Amount | 418108 |
| Total Medicare Allowed Amount | 130868.33 |
| Total Medicare Payment Amount | 101152.17 |
| Total Medicare Standardized Payment Amount | 100692.29 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 113 |
| Number Of Medical Services | 426 |
| Number Of Medicare Beneficiaries With Medical Services | 252 |
| Total Medical Submitted Charge Amount | 418108 |
| Total Medical Medicare Allowed Amount | 130868.33 |
| Total Medical Medicare Payment Amount | 101152.17 |
| Total Medical Medicare Standardized Payment Amount | 100692.29 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 30 |
| Number Of Beneficiaries Age 65 to 74 | 111 |
| Number Of Beneficiaries Age 75 to 84 | 82 |
| Number Of Beneficiaries Age Greater 84 | 29 |
| Number Of Female Beneficiaries | 119 |
| Number Of Male Beneficiaries | 133 |
| Number Of Non Hispanic White Beneficiaries | 170 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 56 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 181 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 71 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 20 |
| Percent Of With Heart Failure | 23 |
| Percent Of With Chronic Kidney Disease | 37 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 39 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 54 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 9 |
| Average HCC Risk Score Of Beneficiaries | 1.7068 |