| National Provider Identifier [NPI]: | 1598833667 |
| Last Name Of The Provider | BANNER |
| First Name Of The Provider | SAM |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1435 W MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | DOTHAN |
| Zip Code Of The Provider | 363011311 |
| State Code Of The Provider | AL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | General Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 29 |
| Number Of Services | 1092 |
| Number Of Medicare Beneficiaries | 158 |
| Total Submitted Charge Amount | 41144.42 |
| Total Medicare Allowed Amount | 26087.59 |
| Total Medicare Payment Amount | 15748.1 |
| Total Medicare Standardized Payment Amount | 18209.45 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 437 |
| Number Of Medicare Beneficiaries With Drug Services | 45 |
| Total Drug Submitted ChargeAmount | 3984.5 |
| Total Drug Medicare AllowedAmount | 356.31 |
| Total Drug Medicare PaymentAmount | 313.72 |
| Total Drug Medicare Standardized Payment Amount | 313.72 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 24 |
| Number Of Medical Services | 655 |
| Number Of Medicare Beneficiaries With Medical Services | 157 |
| Total Medical Submitted Charge Amount | 37159.92 |
| Total Medical Medicare Allowed Amount | 25731.28 |
| Total Medical Medicare Payment Amount | 15434.38 |
| Total Medical Medicare Standardized Payment Amount | 17895.73 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 54 |
| Number Of Beneficiaries Age 65 to 74 | 72 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 90 |
| Number Of Male Beneficiaries | 68 |
| Number Of Non Hispanic White Beneficiaries | 109 |
| 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 | 118 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 40 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 7 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 14 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 30 |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.794 |