| National Provider Identifier [NPI]: | 1902060833 |
| Last Name Of The Provider | KISICKI |
| First Name Of The Provider | DANIEL |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1950 BLUEGRASS CIR |
| Street Address 2 Of The Provider | SUITE 200 |
| City Of The Provider | CHEYENNE |
| Zip Code Of The Provider | 820097323 |
| State Code Of The Provider | WY |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 56 |
| Number Of Services | 632 |
| Number Of Medicare Beneficiaries | 167 |
| Total Submitted Charge Amount | 91618.63 |
| Total Medicare Allowed Amount | 37487.83 |
| Total Medicare Payment Amount | 26954.6 |
| Total Medicare Standardized Payment Amount | 26590.98 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 86 |
| Number Of Medicare Beneficiaries With Drug Services | 33 |
| Total Drug Submitted ChargeAmount | 7953.43 |
| Total Drug Medicare AllowedAmount | 3511.74 |
| Total Drug Medicare PaymentAmount | 2771.18 |
| Total Drug Medicare Standardized Payment Amount | 2771.18 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 46 |
| Number Of Medical Services | 546 |
| Number Of Medicare Beneficiaries With Medical Services | 167 |
| Total Medical Submitted Charge Amount | 83665.2 |
| Total Medical Medicare Allowed Amount | 33976.09 |
| Total Medical Medicare Payment Amount | 24183.42 |
| Total Medical Medicare Standardized Payment Amount | 23819.8 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 81 |
| Number Of Beneficiaries Age 75 to 84 | 43 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 95 |
| Number Of Male Beneficiaries | 72 |
| Number Of Non Hispanic White Beneficiaries | 154 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 139 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 28 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 7 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 17 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 55 |
| Percent Of With Ischemic Heart Disease | 21 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8493 |