| National Provider Identifier [NPI]: | 1679664163 |
| Last Name Of The Provider | FULTZ |
| First Name Of The Provider | JOHN |
| 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 | 1945 W WILSON AVE |
| Street Address 2 Of The Provider | SUITE 5115 |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606405255 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 35 |
| Number Of Services | 1323 |
| Number Of Medicare Beneficiaries | 94 |
| Total Submitted Charge Amount | 153862.09 |
| Total Medicare Allowed Amount | 137537.43 |
| Total Medicare Payment Amount | 106094.44 |
| Total Medicare Standardized Payment Amount | 99497.87 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 47 |
| Number Of Medicare Beneficiaries With Drug Services | 34 |
| Total Drug Submitted ChargeAmount | 1119.66 |
| Total Drug Medicare AllowedAmount | 622.66 |
| Total Drug Medicare PaymentAmount | 604.68 |
| Total Drug Medicare Standardized Payment Amount | 604.68 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 1276 |
| Number Of Medicare Beneficiaries With Medical Services | 94 |
| Total Medical Submitted Charge Amount | 152742.43 |
| Total Medical Medicare Allowed Amount | 136914.77 |
| Total Medical Medicare Payment Amount | 105489.76 |
| Total Medical Medicare Standardized Payment Amount | 98893.19 |
| Average Age Of Beneficiaries | 81 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | 22 |
| Number Of Beneficiaries Age Greater 84 | 47 |
| Number Of Female Beneficiaries | 53 |
| Number Of Male Beneficiaries | 41 |
| 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 | 77 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 17 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 39 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 35 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 31 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 49 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 18 |
| Average HCC Risk Score Of Beneficiaries | 1.5461 |