| National Provider Identifier [NPI]: | 1386619831 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | ROBERT |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 350 W THOMAS RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | PHOENIX |
| Zip Code Of The Provider | 850134409 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 55 |
| Number Of Services | 9306 |
| Number Of Medicare Beneficiaries | 1253 |
| Total Submitted Charge Amount | 862569 |
| Total Medicare Allowed Amount | 181722.3 |
| Total Medicare Payment Amount | 139083.22 |
| Total Medicare Standardized Payment Amount | 141730.82 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 7265 |
| Number Of Medicare Beneficiaries With Drug Services | 106 |
| Total Drug Submitted ChargeAmount | 9776 |
| Total Drug Medicare AllowedAmount | 2965.69 |
| Total Drug Medicare PaymentAmount | 2321.76 |
| Total Drug Medicare Standardized Payment Amount | 2321.76 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 54 |
| Number Of Medical Services | 2041 |
| Number Of Medicare Beneficiaries With Medical Services | 1253 |
| Total Medical Submitted Charge Amount | 852793 |
| Total Medical Medicare Allowed Amount | 178756.61 |
| Total Medical Medicare Payment Amount | 136761.46 |
| Total Medical Medicare Standardized Payment Amount | 139409.06 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 252 |
| Number Of Beneficiaries Age 65 to 74 | 561 |
| Number Of Beneficiaries Age 75 to 84 | 333 |
| Number Of Beneficiaries Age Greater 84 | 107 |
| Number Of Female Beneficiaries | 612 |
| Number Of Male Beneficiaries | 641 |
| Number Of Non Hispanic White Beneficiaries | 966 |
| Number Of Black or African American Beneficiaries | 59 |
| Number Of AsianPacific Islander Beneficiaries | 20 |
| Number Of Hispanic Beneficiaries | 147 |
| Number Of American Indian Alaska Native Beneficiaries | 37 |
| Number Of Beneficiaries With Race Not Else where Classified | 24 |
| Number Of Beneficiaries With Medicare Only Entitlement | 994 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 259 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 19 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 45 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 27 |
| Average HCC Risk Score Of Beneficiaries | 1.6114 |