| National Provider Identifier [NPI]: | 1386695542 |
| Last Name Of The Provider | GRISSOM |
| First Name Of The Provider | TIMOTHY |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2200 RANDALLIA DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468054638 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 196 |
| Number Of Services | 6158 |
| Number Of Medicare Beneficiaries | 4243 |
| Total Submitted Charge Amount | 602942 |
| Total Medicare Allowed Amount | 171607.8 |
| Total Medicare Payment Amount | 135828.2 |
| Total Medicare Standardized Payment Amount | 143943.49 |
| 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 | 196 |
| Number Of Medical Services | 6158 |
| Number Of Medicare Beneficiaries With Medical Services | 4243 |
| Total Medical Submitted Charge Amount | 602942 |
| Total Medical Medicare Allowed Amount | 171607.8 |
| Total Medical Medicare Payment Amount | 135828.2 |
| Total Medical Medicare Standardized Payment Amount | 143943.49 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 882 |
| Number Of Beneficiaries Age 65 to 74 | 1444 |
| Number Of Beneficiaries Age 75 to 84 | 1151 |
| Number Of Beneficiaries Age Greater 84 | 766 |
| Number Of Female Beneficiaries | 2726 |
| Number Of Male Beneficiaries | 1517 |
| Number Of Non Hispanic White Beneficiaries | 3997 |
| Number Of Black or African American Beneficiaries | 136 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 59 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 36 |
| Number Of Beneficiaries With Medicare Only Entitlement | 3136 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 1107 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 15 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 27 |
| Percent Of With Chronic Kidney Disease | 33 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 29 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 10 |
| Percent Of With Stroke | 9 |
| Average HCC Risk Score Of Beneficiaries | 1.4736 |