| National Provider Identifier [NPI]: | 1306920202 |
| Last Name Of The Provider | JOHNSON |
| First Name Of The Provider | MAYBEN |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 526 SHOUP AVE W |
| Street Address 2 Of The Provider | |
| City Of The Provider | TWIN FALLS |
| Zip Code Of The Provider | 83301 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 24 |
| Number Of Services | 442 |
| Number Of Medicare Beneficiaries | 127 |
| Total Submitted Charge Amount | 57090.44 |
| Total Medicare Allowed Amount | 33206.75 |
| Total Medicare Payment Amount | 23335.31 |
| Total Medicare Standardized Payment Amount | 25326.34 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 20 |
| Number Of Medicare Beneficiaries With Drug Services | 19 |
| Total Drug Submitted ChargeAmount | 526 |
| Total Drug Medicare AllowedAmount | 396.74 |
| Total Drug Medicare PaymentAmount | 388.78 |
| Total Drug Medicare Standardized Payment Amount | 388.78 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 422 |
| Number Of Medicare Beneficiaries With Medical Services | 127 |
| Total Medical Submitted Charge Amount | 56564.44 |
| Total Medical Medicare Allowed Amount | 32810.01 |
| Total Medical Medicare Payment Amount | 22946.53 |
| Total Medical Medicare Standardized Payment Amount | 24937.56 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 29 |
| Number Of Beneficiaries Age 65 to 74 | 38 |
| Number Of Beneficiaries Age 75 to 84 | 38 |
| Number Of Beneficiaries Age Greater 84 | 22 |
| Number Of Female Beneficiaries | 63 |
| Number Of Male Beneficiaries | 64 |
| 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 | 75 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 52 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 20 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 40 |
| Percent Of With Hypertension | 54 |
| Percent Of With Ischemic Heart Disease | 22 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 27 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.3724 |