| National Provider Identifier [NPI]: | 1306842182 |
| Last Name Of The Provider | GUSTAVEL |
| First Name Of The Provider | MICHAEL |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1188 UNIVERSITY DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | BOISE |
| Zip Code Of The Provider | 837063009 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Orthopedic Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 799 |
| Number Of Medicare Beneficiaries | 83 |
| Total Submitted Charge Amount | 159110 |
| Total Medicare Allowed Amount | 43626.32 |
| Total Medicare Payment Amount | 33409.66 |
| Total Medicare Standardized Payment Amount | 36134.5 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 464 |
| Number Of Medicare Beneficiaries With Drug Services | 37 |
| Total Drug Submitted ChargeAmount | 2560 |
| Total Drug Medicare AllowedAmount | 1002.79 |
| Total Drug Medicare PaymentAmount | 777.34 |
| Total Drug Medicare Standardized Payment Amount | 777.34 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 43 |
| Number Of Medical Services | 335 |
| Number Of Medicare Beneficiaries With Medical Services | 83 |
| Total Medical Submitted Charge Amount | 156550 |
| Total Medical Medicare Allowed Amount | 42623.53 |
| Total Medical Medicare Payment Amount | 32632.32 |
| Total Medical Medicare Standardized Payment Amount | 35357.16 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 62 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 41 |
| Number Of Male Beneficiaries | 42 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 0 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 14 |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | 36 |
| Percent Of With Hypertension | 41 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 66 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 0.64 |