| National Provider Identifier [NPI]: | 1124193503 |
| Last Name Of The Provider | WISSINK |
| First Name Of The Provider | THEODORE |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 272 CONGRESS ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | PORTLAND |
| Zip Code Of The Provider | 04101 |
| State Code Of The Provider | ME |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 34 |
| Number Of Services | 781 |
| Number Of Medicare Beneficiaries | 359 |
| Total Submitted Charge Amount | 79844 |
| Total Medicare Allowed Amount | 56873.13 |
| Total Medicare Payment Amount | 41829.94 |
| Total Medicare Standardized Payment Amount | 42356.25 |
| 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 | 34 |
| Number Of Medical Services | 781 |
| Number Of Medicare Beneficiaries With Medical Services | 359 |
| Total Medical Submitted Charge Amount | 79844 |
| Total Medical Medicare Allowed Amount | 56873.13 |
| Total Medical Medicare Payment Amount | 41829.94 |
| Total Medical Medicare Standardized Payment Amount | 42356.25 |
| Average Age Of Beneficiaries | 62 |
| Number Of Beneficiaries Age Less65 | 174 |
| Number Of Beneficiaries Age 65 to 74 | 111 |
| Number Of Beneficiaries Age 75 to 84 | 47 |
| Number Of Beneficiaries Age Greater 84 | 27 |
| Number Of Female Beneficiaries | 193 |
| Number Of Male Beneficiaries | 166 |
| Number Of Non Hispanic White Beneficiaries | 334 |
| 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 | 105 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 254 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 23 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 48 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 28 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 11 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.5015 |