| National Provider Identifier [NPI]: | 1053369546 |
| Last Name Of The Provider | JACQUOT |
| First Name Of The Provider | BRIAN |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | P.A.-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2300 N EDWARD ST |
| Street Address 2 Of The Provider | SUITE 2350 |
| City Of The Provider | DECATUR |
| Zip Code Of The Provider | 625264163 |
| 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 | 55 |
| Number Of Services | 667 |
| Number Of Medicare Beneficiaries | 185 |
| Total Submitted Charge Amount | 360651.36 |
| Total Medicare Allowed Amount | 27669.01 |
| Total Medicare Payment Amount | 22272.09 |
| Total Medicare Standardized Payment Amount | 24470.94 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 109 |
| Number Of Medicare Beneficiaries With Drug Services | 78 |
| Total Drug Submitted ChargeAmount | 3124.34 |
| Total Drug Medicare AllowedAmount | 1850.03 |
| Total Drug Medicare PaymentAmount | 1792.13 |
| Total Drug Medicare Standardized Payment Amount | 1792.13 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 46 |
| Number Of Medical Services | 558 |
| Number Of Medicare Beneficiaries With Medical Services | 185 |
| Total Medical Submitted Charge Amount | 357527.02 |
| Total Medical Medicare Allowed Amount | 25818.98 |
| Total Medical Medicare Payment Amount | 20479.96 |
| Total Medical Medicare Standardized Payment Amount | 22678.81 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 16 |
| Number Of Beneficiaries Age 65 to 74 | 75 |
| Number Of Beneficiaries Age 75 to 84 | 68 |
| Number Of Beneficiaries Age Greater 84 | 26 |
| Number Of Female Beneficiaries | 116 |
| Number Of Male Beneficiaries | 69 |
| 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 | 162 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 23 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 19 |
| Percent Of With Heart Failure | 31 |
| Percent Of With Chronic Kidney Disease | 33 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 25 |
| Percent Of With Depression | 30 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 48 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2817 |