| National Provider Identifier [NPI]: | 1639244486 |
| Last Name Of The Provider | FORMAN |
| First Name Of The Provider | MITCHELL |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1644 BRUCE B DOWNS BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | WESLEY CHAPEL |
| Zip Code Of The Provider | 335448600 |
| 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 | 66 |
| Number Of Services | 1570 |
| Number Of Medicare Beneficiaries | 558 |
| Total Submitted Charge Amount | 140656.64 |
| Total Medicare Allowed Amount | 93543.9 |
| Total Medicare Payment Amount | 65289.37 |
| Total Medicare Standardized Payment Amount | 66247.78 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 13 |
| Number Of Drug Services | 352 |
| Number Of Medicare Beneficiaries With Drug Services | 54 |
| Total Drug Submitted ChargeAmount | 1025.98 |
| Total Drug Medicare AllowedAmount | 422.98 |
| Total Drug Medicare PaymentAmount | 358.99 |
| Total Drug Medicare Standardized Payment Amount | 358.99 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 53 |
| Number Of Medical Services | 1218 |
| Number Of Medicare Beneficiaries With Medical Services | 558 |
| Total Medical Submitted Charge Amount | 139630.66 |
| Total Medical Medicare Allowed Amount | 93120.92 |
| Total Medical Medicare Payment Amount | 64930.38 |
| Total Medical Medicare Standardized Payment Amount | 65888.79 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 60 |
| Number Of Beneficiaries Age 65 to 74 | 318 |
| Number Of Beneficiaries Age 75 to 84 | 136 |
| Number Of Beneficiaries Age Greater 84 | 44 |
| Number Of Female Beneficiaries | 329 |
| Number Of Male Beneficiaries | 229 |
| Number Of Non Hispanic White Beneficiaries | 483 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 38 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 519 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 39 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 63 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.0059 |