| National Provider Identifier [NPI]: | 1629066857 |
| Last Name Of The Provider | WALLER |
| First Name Of The Provider | THOMAS |
| 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 | 4500 SAN PABLO RD S |
| Street Address 2 Of The Provider | |
| City Of The Provider | JACKSONVILLE |
| Zip Code Of The Provider | 322241865 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 62 |
| Number Of Services | 1665 |
| Number Of Medicare Beneficiaries | 841 |
| Total Submitted Charge Amount | 140373.62 |
| Total Medicare Allowed Amount | 120291.35 |
| Total Medicare Payment Amount | 87075.31 |
| Total Medicare Standardized Payment Amount | 93193.19 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 14 |
| Number Of Drug Services | 197 |
| Number Of Medicare Beneficiaries With Drug Services | 128 |
| Total Drug Submitted ChargeAmount | 7953.9 |
| Total Drug Medicare AllowedAmount | 7595.5 |
| Total Drug Medicare PaymentAmount | 7391.07 |
| Total Drug Medicare Standardized Payment Amount | 7391.07 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 48 |
| Number Of Medical Services | 1468 |
| Number Of Medicare Beneficiaries With Medical Services | 837 |
| Total Medical Submitted Charge Amount | 132419.72 |
| Total Medical Medicare Allowed Amount | 112695.85 |
| Total Medical Medicare Payment Amount | 79684.24 |
| Total Medical Medicare Standardized Payment Amount | 85802.12 |
| Average Age Of Beneficiaries | 78 |
| Number Of Beneficiaries Age Less65 | 36 |
| Number Of Beneficiaries Age 65 to 74 | 257 |
| Number Of Beneficiaries Age 75 to 84 | 343 |
| Number Of Beneficiaries Age Greater 84 | 205 |
| Number Of Female Beneficiaries | 487 |
| Number Of Male Beneficiaries | 354 |
| Number Of Non Hispanic White Beneficiaries | 765 |
| Number Of Black or African American Beneficiaries | 34 |
| Number Of AsianPacific Islander Beneficiaries | 11 |
| Number Of Hispanic Beneficiaries | 20 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 810 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 31 |
| Percent Of With Atrial Fibrillation | 20 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 43 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.1197 |