| National Provider Identifier [NPI]: | 1942294376 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | THEODORE |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1306 KANAWHA BLVD E |
| Street Address 2 Of The Provider | SUITE 100 |
| City Of The Provider | CHARLESTON |
| Zip Code Of The Provider | 253013001 |
| State Code Of The Provider | WV |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Plastic and Reconstructive Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 95 |
| Number Of Services | 1800 |
| Number Of Medicare Beneficiaries | 480 |
| Total Submitted Charge Amount | 564238.37 |
| Total Medicare Allowed Amount | 199780.17 |
| Total Medicare Payment Amount | 146940.36 |
| Total Medicare Standardized Payment Amount | 152805.56 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 609 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 22335 |
| Total Drug Medicare AllowedAmount | 20933.98 |
| Total Drug Medicare PaymentAmount | 16412.24 |
| Total Drug Medicare Standardized Payment Amount | 16412.24 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 93 |
| Number Of Medical Services | 1191 |
| Number Of Medicare Beneficiaries With Medical Services | 480 |
| Total Medical Submitted Charge Amount | 541903.37 |
| Total Medical Medicare Allowed Amount | 178846.19 |
| Total Medical Medicare Payment Amount | 130528.12 |
| Total Medical Medicare Standardized Payment Amount | 136393.32 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 79 |
| Number Of Beneficiaries Age 65 to 74 | 216 |
| Number Of Beneficiaries Age 75 to 84 | 131 |
| Number Of Beneficiaries Age Greater 84 | 54 |
| Number Of Female Beneficiaries | 260 |
| Number Of Male Beneficiaries | 220 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 402 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 78 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 37 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.1744 |