| National Provider Identifier [NPI]: | 1871506931 |
| Last Name Of The Provider | SODERSTROM |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | P.A. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4909 N GLEN PARK PLACE RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | PEORIA |
| Zip Code Of The Provider | 616144676 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 50 |
| Number Of Services | 7409 |
| Number Of Medicare Beneficiaries | 880 |
| Total Submitted Charge Amount | 378608.42 |
| Total Medicare Allowed Amount | 304664.53 |
| Total Medicare Payment Amount | 222056.59 |
| Total Medicare Standardized Payment Amount | 264027.09 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 222 |
| Number Of Medicare Beneficiaries With Drug Services | 126 |
| Total Drug Submitted ChargeAmount | 4644.34 |
| Total Drug Medicare AllowedAmount | 395.54 |
| Total Drug Medicare PaymentAmount | 277.99 |
| Total Drug Medicare Standardized Payment Amount | 277.99 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 48 |
| Number Of Medical Services | 7187 |
| Number Of Medicare Beneficiaries With Medical Services | 880 |
| Total Medical Submitted Charge Amount | 373964.08 |
| Total Medical Medicare Allowed Amount | 304268.99 |
| Total Medical Medicare Payment Amount | 221778.6 |
| Total Medical Medicare Standardized Payment Amount | 263749.1 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 61 |
| Number Of Beneficiaries Age 65 to 74 | 362 |
| Number Of Beneficiaries Age 75 to 84 | 305 |
| Number Of Beneficiaries Age Greater 84 | 152 |
| Number Of Female Beneficiaries | 394 |
| Number Of Male Beneficiaries | 486 |
| Number Of Non Hispanic White Beneficiaries | 854 |
| Number Of Black or African American Beneficiaries | 14 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 803 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 77 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 14 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 4 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 3 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.0593 |