| National Provider Identifier [NPI]: | 1528302080 |
| Last Name Of The Provider | SISKOVICH |
| First Name Of The Provider | THEODORE |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1000 E MOUNTAIN BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | WILKES BARRE |
| Zip Code Of The Provider | 187110027 |
| State Code Of The Provider | PA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 20 |
| Number Of Services | 270 |
| Number Of Medicare Beneficiaries | 246 |
| Total Submitted Charge Amount | 135127 |
| Total Medicare Allowed Amount | 23309.52 |
| Total Medicare Payment Amount | 16684.75 |
| Total Medicare Standardized Payment Amount | 20501.39 |
| 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 | 20 |
| Number Of Medical Services | 270 |
| Number Of Medicare Beneficiaries With Medical Services | 246 |
| Total Medical Submitted Charge Amount | 135127 |
| Total Medical Medicare Allowed Amount | 23309.52 |
| Total Medical Medicare Payment Amount | 16684.75 |
| Total Medical Medicare Standardized Payment Amount | 20501.39 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 101 |
| Number Of Beneficiaries Age 65 to 74 | 66 |
| Number Of Beneficiaries Age 75 to 84 | 48 |
| Number Of Beneficiaries Age Greater 84 | 31 |
| Number Of Female Beneficiaries | 137 |
| Number Of Male Beneficiaries | 109 |
| Number Of Non Hispanic White Beneficiaries | 227 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| 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 | 138 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 108 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 28 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 62 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 52 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.4753 |