| National Provider Identifier [NPI]: | 1679641666 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | THOMAS |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1441 FLORIDA AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MODESTO |
| Zip Code Of The Provider | 953504405 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 19 |
| Number Of Services | 1338 |
| Number Of Medicare Beneficiaries | 633 |
| Total Submitted Charge Amount | 231835 |
| Total Medicare Allowed Amount | 107627.9 |
| Total Medicare Payment Amount | 84107.84 |
| Total Medicare Standardized Payment Amount | 82057.69 |
| 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 | 19 |
| Number Of Medical Services | 1338 |
| Number Of Medicare Beneficiaries With Medical Services | 633 |
| Total Medical Submitted Charge Amount | 231835 |
| Total Medical Medicare Allowed Amount | 107627.9 |
| Total Medical Medicare Payment Amount | 84107.84 |
| Total Medical Medicare Standardized Payment Amount | 82057.69 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 146 |
| Number Of Beneficiaries Age 65 to 74 | 209 |
| Number Of Beneficiaries Age 75 to 84 | 179 |
| Number Of Beneficiaries Age Greater 84 | 99 |
| Number Of Female Beneficiaries | 335 |
| Number Of Male Beneficiaries | 298 |
| Number Of Non Hispanic White Beneficiaries | 430 |
| Number Of Black or African American Beneficiaries | 27 |
| Number Of AsianPacific Islander Beneficiaries | 33 |
| Number Of Hispanic Beneficiaries | 131 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 290 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 343 |
| Percent Of With Atrial Fibrillation | 27 |
| Percent Of With Alzheimers Disease or Dementia | 24 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 50 |
| Percent Of With Chronic Kidney Disease | 59 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 35 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 54 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 62 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 12 |
| Percent Of With Stroke | 18 |
| Average HCC Risk Score Of Beneficiaries | 2.3983 |