| National Provider Identifier [NPI]: | 1669540308 |
| Last Name Of The Provider | MANDAVA |
| First Name Of The Provider | SABALA |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | HENRY FORD HEALTH SYSTEM |
| Street Address 2 Of The Provider | 2799 WEST GRAND BOULEVARD |
| City Of The Provider | DETROIT |
| Zip Code Of The Provider | 48202 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 15 |
| Number Of Services | 722 |
| Number Of Medicare Beneficiaries | 644 |
| Total Submitted Charge Amount | 86823 |
| Total Medicare Allowed Amount | 29521.24 |
| Total Medicare Payment Amount | 26192.16 |
| Total Medicare Standardized Payment Amount | 25287.95 |
| 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 | 15 |
| Number Of Medical Services | 722 |
| Number Of Medicare Beneficiaries With Medical Services | 644 |
| Total Medical Submitted Charge Amount | 86823 |
| Total Medical Medicare Allowed Amount | 29521.24 |
| Total Medical Medicare Payment Amount | 26192.16 |
| Total Medical Medicare Standardized Payment Amount | 25287.95 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 120 |
| Number Of Beneficiaries Age 65 to 74 | 351 |
| Number Of Beneficiaries Age 75 to 84 | 139 |
| Number Of Beneficiaries Age Greater 84 | 34 |
| Number Of Female Beneficiaries | |
| Number Of Male Beneficiaries | |
| Number Of Non Hispanic White Beneficiaries | 339 |
| Number Of Black or African American Beneficiaries | 251 |
| Number Of AsianPacific Islander Beneficiaries | 25 |
| 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 | 510 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 134 |
| Percent Of With Atrial Fibrillation | 5 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 8 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 19 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 0.9637 |