| National Provider Identifier [NPI]: | 1518131093 |
| Last Name Of The Provider | NISSLY |
| First Name Of The Provider | TANNER |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1020 W BROADWAY AVE |
| Street Address 2 Of The Provider | BROADWAY FAMILY MEDICINE |
| City Of The Provider | MINNEAPOLIS |
| Zip Code Of The Provider | 554112504 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 63 |
| Number Of Services | 837 |
| Number Of Medicare Beneficiaries | 197 |
| Total Submitted Charge Amount | 117340 |
| Total Medicare Allowed Amount | 44591.96 |
| Total Medicare Payment Amount | 34743.63 |
| Total Medicare Standardized Payment Amount | 36098.26 |
| Drug Suppress Indicator | * |
| Number Of HCPCS Associated With Drug Services | |
| Number Of Drug Services | |
| Number Of Medicare Beneficiaries With Drug Services | |
| Total Drug Submitted ChargeAmount | |
| Total Drug Medicare AllowedAmount | |
| Total Drug Medicare PaymentAmount | |
| Total Drug Medicare Standardized Payment Amount | |
| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
| Number Of Medical Services | |
| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
| Total Medical Medicare Payment Amount | |
| Total Medical Medicare Standardized Payment Amount | |
| Average Age Of Beneficiaries | 61 |
| Number Of Beneficiaries Age Less65 | 114 |
| Number Of Beneficiaries Age 65 to 74 | 39 |
| Number Of Beneficiaries Age 75 to 84 | 30 |
| Number Of Beneficiaries Age Greater 84 | 14 |
| Number Of Female Beneficiaries | 100 |
| Number Of Male Beneficiaries | 97 |
| Number Of Non Hispanic White Beneficiaries | 94 |
| Number Of Black or African American Beneficiaries | 92 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 52 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 145 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 21 |
| Percent Of With Asthma | 25 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 30 |
| Percent Of With Chronic Kidney Disease | 50 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 25 |
| Percent Of With Depression | 46 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 42 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 29 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 21 |
| Percent Of With Stroke | 12 |
| Average HCC Risk Score Of Beneficiaries | 2.4761 |