| National Provider Identifier [NPI]: | 1811039555 |
| Last Name Of The Provider | FULLERTON |
| First Name Of The Provider | PATRICK |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 303 N CLYDE MORRIS BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | DAYTONA BEACH |
| Zip Code Of The Provider | 321142709 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 30 |
| Number Of Services | 216 |
| Number Of Medicare Beneficiaries | 175 |
| Total Submitted Charge Amount | 184261.62 |
| Total Medicare Allowed Amount | 27265.37 |
| Total Medicare Payment Amount | 20144.62 |
| Total Medicare Standardized Payment Amount | 19880.12 |
| Drug Suppress Indicator | * |
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| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
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| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
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| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 62 |
| Number Of Beneficiaries Age 65 to 74 | 46 |
| Number Of Beneficiaries Age 75 to 84 | 37 |
| Number Of Beneficiaries Age Greater 84 | 30 |
| Number Of Female Beneficiaries | 100 |
| Number Of Male Beneficiaries | 75 |
| Number Of Non Hispanic White Beneficiaries | 145 |
| Number Of Black or African American Beneficiaries | 14 |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| 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 | 99 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 76 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 19 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 31 |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 30 |
| Percent Of With Depression | 37 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 37 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 43 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | 13 |
| Average HCC Risk Score Of Beneficiaries | 1.5238 |