| National Provider Identifier [NPI]: | 1609978808 |
| Last Name Of The Provider | LICK |
| First Name Of The Provider | JAY |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 635 E. BASELINE RD. |
| Street Address 2 Of The Provider | |
| City Of The Provider | PHOENIX |
| Zip Code Of The Provider | 85042 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Obstetrics/Gynecology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 80 |
| Number Of Services | 343 |
| Number Of Medicare Beneficiaries | 149 |
| Total Submitted Charge Amount | 87850 |
| Total Medicare Allowed Amount | 19858.36 |
| Total Medicare Payment Amount | 14642.93 |
| Total Medicare Standardized Payment Amount | 15228.75 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 84 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 1782 |
| Total Drug Medicare AllowedAmount | 98.86 |
| Total Drug Medicare PaymentAmount | 51.17 |
| Total Drug Medicare Standardized Payment Amount | 51.17 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 68 |
| Number Of Medical Services | 259 |
| Number Of Medicare Beneficiaries With Medical Services | 149 |
| Total Medical Submitted Charge Amount | 86068 |
| Total Medical Medicare Allowed Amount | 19759.5 |
| Total Medical Medicare Payment Amount | 14591.76 |
| Total Medical Medicare Standardized Payment Amount | 15177.58 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 52 |
| Number Of Beneficiaries Age 65 to 74 | 55 |
| Number Of Beneficiaries Age 75 to 84 | 29 |
| Number Of Beneficiaries Age Greater 84 | 13 |
| Number Of Female Beneficiaries | 116 |
| Number Of Male Beneficiaries | 33 |
| Number Of Non Hispanic White Beneficiaries | 126 |
| Number Of Black or African American Beneficiaries | 11 |
| 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 | 105 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 44 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1144 |