| National Provider Identifier [NPI]: | 1366419525 |
| Last Name Of The Provider | LICK |
| First Name Of The Provider | CHARLES |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 303 CATLIN ST |
| Street Address 2 Of The Provider | BUFFALO HOSPITAL |
| City Of The Provider | BUFFALO |
| Zip Code Of The Provider | 55313 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 19 |
| Number Of Services | 472 |
| Number Of Medicare Beneficiaries | 329 |
| Total Submitted Charge Amount | 202396 |
| Total Medicare Allowed Amount | 44098.95 |
| Total Medicare Payment Amount | 32737.1 |
| Total Medicare Standardized Payment Amount | 34289.14 |
| 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 | 19 |
| Number Of Medical Services | 472 |
| Number Of Medicare Beneficiaries With Medical Services | 329 |
| Total Medical Submitted Charge Amount | 202396 |
| Total Medical Medicare Allowed Amount | 44098.95 |
| Total Medical Medicare Payment Amount | 32737.1 |
| Total Medical Medicare Standardized Payment Amount | 34289.14 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 135 |
| Number Of Beneficiaries Age 65 to 74 | 44 |
| Number Of Beneficiaries Age 75 to 84 | 88 |
| Number Of Beneficiaries Age Greater 84 | 62 |
| Number Of Female Beneficiaries | 201 |
| Number Of Male Beneficiaries | 128 |
| Number Of Non Hispanic White Beneficiaries | 293 |
| Number Of Black or African American Beneficiaries | 21 |
| 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 | 189 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 140 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 19 |
| Percent Of With Asthma | 20 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 40 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 22 |
| Percent Of With Depression | 48 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 16 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.856 |