| National Provider Identifier [NPI]: | 1396742318 |
| Last Name Of The Provider | THERIAULT |
| First Name Of The Provider | VICTOR |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 712 WILLIS AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | BOGALUSA |
| Zip Code Of The Provider | 704273004 |
| State Code Of The Provider | LA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 59 |
| Number Of Services | 2034 |
| Number Of Medicare Beneficiaries | 195 |
| Total Submitted Charge Amount | 163639 |
| Total Medicare Allowed Amount | 120668.84 |
| Total Medicare Payment Amount | 85594.56 |
| Total Medicare Standardized Payment Amount | 91475.17 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 402 |
| Number Of Medicare Beneficiaries With Drug Services | 132 |
| Total Drug Submitted ChargeAmount | 5148 |
| Total Drug Medicare AllowedAmount | 2868.28 |
| Total Drug Medicare PaymentAmount | 2369.96 |
| Total Drug Medicare Standardized Payment Amount | 2369.96 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 49 |
| Number Of Medical Services | 1632 |
| Number Of Medicare Beneficiaries With Medical Services | 195 |
| Total Medical Submitted Charge Amount | 158491 |
| Total Medical Medicare Allowed Amount | 117800.56 |
| Total Medical Medicare Payment Amount | 83224.6 |
| Total Medical Medicare Standardized Payment Amount | 89105.21 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 23 |
| Number Of Beneficiaries Age 65 to 74 | 77 |
| Number Of Beneficiaries Age 75 to 84 | 56 |
| Number Of Beneficiaries Age Greater 84 | 39 |
| Number Of Female Beneficiaries | 122 |
| Number Of Male Beneficiaries | 73 |
| Number Of Non Hispanic White Beneficiaries | 159 |
| Number Of Black or African American Beneficiaries | 36 |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 131 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 64 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 29 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 54 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 62 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 66 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1833 |