| National Provider Identifier [NPI]: | 1023002755 |
| Last Name Of The Provider | CONNALLY |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 10500 STEPPINGTON DR |
| Street Address 2 Of The Provider | SUITE 100A |
| City Of The Provider | DALLAS |
| Zip Code Of The Provider | 752304561 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 84 |
| Number Of Services | 8772 |
| Number Of Medicare Beneficiaries | 626 |
| Total Submitted Charge Amount | 1482697 |
| Total Medicare Allowed Amount | 284665.66 |
| Total Medicare Payment Amount | 216895.41 |
| Total Medicare Standardized Payment Amount | 214010.52 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 6656 |
| Number Of Medicare Beneficiaries With Drug Services | 220 |
| Total Drug Submitted ChargeAmount | 68700 |
| Total Drug Medicare AllowedAmount | 1239.02 |
| Total Drug Medicare PaymentAmount | 955.12 |
| Total Drug Medicare Standardized Payment Amount | 955.12 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 82 |
| Number Of Medical Services | 2116 |
| Number Of Medicare Beneficiaries With Medical Services | 626 |
| Total Medical Submitted Charge Amount | 1413997 |
| Total Medical Medicare Allowed Amount | 283426.64 |
| Total Medical Medicare Payment Amount | 215940.29 |
| Total Medical Medicare Standardized Payment Amount | 213055.4 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 79 |
| Number Of Beneficiaries Age 65 to 74 | 302 |
| Number Of Beneficiaries Age 75 to 84 | 197 |
| Number Of Beneficiaries Age Greater 84 | 48 |
| Number Of Female Beneficiaries | 385 |
| Number Of Male Beneficiaries | 241 |
| Number Of Non Hispanic White Beneficiaries | 535 |
| Number Of Black or African American Beneficiaries | 45 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 34 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 574 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 52 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 67 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.0535 |