| National Provider Identifier [NPI]: | 1245441971 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | SETH |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 11576 S STATE ST STE 102A |
| Street Address 2 Of The Provider | |
| City Of The Provider | DRAPER |
| Zip Code Of The Provider | 840207121 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 44 |
| Number Of Services | 235 |
| Number Of Medicare Beneficiaries | 117 |
| Total Submitted Charge Amount | 55841 |
| Total Medicare Allowed Amount | 20313.55 |
| Total Medicare Payment Amount | 15675.25 |
| Total Medicare Standardized Payment Amount | 16507 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 45 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 832 |
| Total Drug Medicare AllowedAmount | 598.1 |
| Total Drug Medicare PaymentAmount | 583.01 |
| Total Drug Medicare Standardized Payment Amount | 583.01 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 35 |
| Number Of Medical Services | 190 |
| Number Of Medicare Beneficiaries With Medical Services | 117 |
| Total Medical Submitted Charge Amount | 55009 |
| Total Medical Medicare Allowed Amount | 19715.45 |
| Total Medical Medicare Payment Amount | 15092.24 |
| Total Medical Medicare Standardized Payment Amount | 15923.99 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 20 |
| Number Of Beneficiaries Age 65 to 74 | 51 |
| Number Of Beneficiaries Age 75 to 84 | 33 |
| Number Of Beneficiaries Age Greater 84 | 13 |
| Number Of Female Beneficiaries | 73 |
| Number Of Male Beneficiaries | 44 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 29 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.876 |