| National Provider Identifier [NPI]: | 1265618136 |
| Last Name Of The Provider | GUSTIN |
| First Name Of The Provider | STACY |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4840 E INDIAN SCHOOL RD |
| Street Address 2 Of The Provider | SUITE 100 |
| City Of The Provider | PHOENIX |
| Zip Code Of The Provider | 850185500 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 32 |
| Number Of Services | 390 |
| Number Of Medicare Beneficiaries | 140 |
| Total Submitted Charge Amount | 68737.91 |
| Total Medicare Allowed Amount | 30957.67 |
| Total Medicare Payment Amount | 21005.32 |
| Total Medicare Standardized Payment Amount | 21368.78 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 31 |
| Number Of Medicare Beneficiaries With Drug Services | 25 |
| Total Drug Submitted ChargeAmount | 1286.66 |
| Total Drug Medicare AllowedAmount | 793.27 |
| Total Drug Medicare PaymentAmount | 772.45 |
| Total Drug Medicare Standardized Payment Amount | 772.45 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 22 |
| Number Of Medical Services | 359 |
| Number Of Medicare Beneficiaries With Medical Services | 140 |
| Total Medical Submitted Charge Amount | 67451.25 |
| Total Medical Medicare Allowed Amount | 30164.4 |
| Total Medical Medicare Payment Amount | 20232.87 |
| Total Medical Medicare Standardized Payment Amount | 20596.33 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 15 |
| Number Of Beneficiaries Age 65 to 74 | 71 |
| Number Of Beneficiaries Age 75 to 84 | 39 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 89 |
| Number Of Male Beneficiaries | 51 |
| Number Of Non Hispanic White Beneficiaries | 126 |
| 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 | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 122 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 18 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 8 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 14 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 56 |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 16 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8438 |