| National Provider Identifier [NPI]: | 1467479550 |
| Last Name Of The Provider | STORK |
| First Name Of The Provider | JERRY |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | P.A. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3688 VETERANS MEMORIAL DR |
| Street Address 2 Of The Provider | 200 |
| City Of The Provider | HATTIESBURG |
| Zip Code Of The Provider | 394018246 |
| State Code Of The Provider | MS |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 21 |
| Number Of Services | 467 |
| Number Of Medicare Beneficiaries | 361 |
| Total Submitted Charge Amount | 361274 |
| Total Medicare Allowed Amount | 38378.17 |
| Total Medicare Payment Amount | 29493.22 |
| Total Medicare Standardized Payment Amount | 36510.98 |
| 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 | 21 |
| Number Of Medical Services | 467 |
| Number Of Medicare Beneficiaries With Medical Services | 361 |
| Total Medical Submitted Charge Amount | 361274 |
| Total Medical Medicare Allowed Amount | 38378.17 |
| Total Medical Medicare Payment Amount | 29493.22 |
| Total Medical Medicare Standardized Payment Amount | 36510.98 |
| Average Age Of Beneficiaries | 60 |
| Number Of Beneficiaries Age Less65 | 197 |
| Number Of Beneficiaries Age 65 to 74 | 90 |
| Number Of Beneficiaries Age 75 to 84 | 53 |
| Number Of Beneficiaries Age Greater 84 | 21 |
| Number Of Female Beneficiaries | 242 |
| Number Of Male Beneficiaries | 119 |
| Number Of Non Hispanic White Beneficiaries | 255 |
| Number Of Black or African American Beneficiaries | 93 |
| 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 | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 175 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 186 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 40 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 51 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.3665 |