| National Provider Identifier [NPI]: | 1720269731 |
| Last Name Of The Provider | LICUP |
| First Name Of The Provider | NERISSA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1021 W OAKLAND AVE |
| Street Address 2 Of The Provider | SUITE 301 |
| City Of The Provider | JOHNSON CITY |
| Zip Code Of The Provider | 376042191 |
| State Code Of The Provider | TN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 39 |
| Number Of Services | 1142 |
| Number Of Medicare Beneficiaries | 255 |
| Total Submitted Charge Amount | 147102 |
| Total Medicare Allowed Amount | 71133.54 |
| Total Medicare Payment Amount | 49402.13 |
| Total Medicare Standardized Payment Amount | 54223.26 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 117 |
| Number Of Medicare Beneficiaries With Drug Services | 81 |
| Total Drug Submitted ChargeAmount | 3834 |
| Total Drug Medicare AllowedAmount | 2889.25 |
| Total Drug Medicare PaymentAmount | 2797.9 |
| Total Drug Medicare Standardized Payment Amount | 2797.9 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 30 |
| Number Of Medical Services | 1025 |
| Number Of Medicare Beneficiaries With Medical Services | 255 |
| Total Medical Submitted Charge Amount | 143268 |
| Total Medical Medicare Allowed Amount | 68244.29 |
| Total Medical Medicare Payment Amount | 46604.23 |
| Total Medical Medicare Standardized Payment Amount | 51425.36 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 73 |
| Number Of Beneficiaries Age 65 to 74 | 113 |
| Number Of Beneficiaries Age 75 to 84 | 54 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 168 |
| Number Of Male Beneficiaries | 87 |
| Number Of Non Hispanic White Beneficiaries | 241 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 182 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 73 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 42 |
| Percent Of With Hypertension | 69 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.2569 |