| National Provider Identifier [NPI]: | 1366462046 |
| Last Name Of The Provider | MULLALLY |
| First Name Of The Provider | TIMOTHY |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 12800 MISSISSIPPI PKWY |
| Street Address 2 Of The Provider | A200 |
| City Of The Provider | CROWN POINT |
| Zip Code Of The Provider | 463076900 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Sports Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 48 |
| Number Of Services | 1623 |
| Number Of Medicare Beneficiaries | 242 |
| Total Submitted Charge Amount | 178258.3 |
| Total Medicare Allowed Amount | 118289.42 |
| Total Medicare Payment Amount | 87194.39 |
| Total Medicare Standardized Payment Amount | 91910.3 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 186 |
| Number Of Medicare Beneficiaries With Drug Services | 83 |
| Total Drug Submitted ChargeAmount | 12556.84 |
| Total Drug Medicare AllowedAmount | 7639.49 |
| Total Drug Medicare PaymentAmount | 6022.69 |
| Total Drug Medicare Standardized Payment Amount | 6022.69 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 39 |
| Number Of Medical Services | 1437 |
| Number Of Medicare Beneficiaries With Medical Services | 242 |
| Total Medical Submitted Charge Amount | 165701.46 |
| Total Medical Medicare Allowed Amount | 110649.93 |
| Total Medical Medicare Payment Amount | 81171.7 |
| Total Medical Medicare Standardized Payment Amount | 85887.61 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 24 |
| Number Of Beneficiaries Age 65 to 74 | 133 |
| Number Of Beneficiaries Age 75 to 84 | 70 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 125 |
| Number Of Male Beneficiaries | 117 |
| 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 | 227 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 15 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 42 |
| Percent Of With Hyperlipidemia | 64 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 33 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 0.9938 |