| National Provider Identifier [NPI]: | 1356447882 |
| Last Name Of The Provider | GOODRICH |
| First Name Of The Provider | MARK |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | PAC |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1477 NORTH 2000 WEST |
| Street Address 2 Of The Provider | WESTSIDE MEDICAL |
| City Of The Provider | CLINTON |
| Zip Code Of The Provider | 84015 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 52 |
| Number Of Services | 496 |
| Number Of Medicare Beneficiaries | 114 |
| Total Submitted Charge Amount | 28719.85 |
| Total Medicare Allowed Amount | 19679.42 |
| Total Medicare Payment Amount | 13529.78 |
| Total Medicare Standardized Payment Amount | 16702.9 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 120 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 1478.25 |
| Total Drug Medicare AllowedAmount | 374.8 |
| Total Drug Medicare PaymentAmount | 273.13 |
| Total Drug Medicare Standardized Payment Amount | 273.13 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 40 |
| Number Of Medical Services | 376 |
| Number Of Medicare Beneficiaries With Medical Services | 114 |
| Total Medical Submitted Charge Amount | 27241.6 |
| Total Medical Medicare Allowed Amount | 19304.62 |
| Total Medical Medicare Payment Amount | 13256.65 |
| Total Medical Medicare Standardized Payment Amount | 16429.77 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 68 |
| Number Of Beneficiaries Age 75 to 84 | 25 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 62 |
| Number Of Male Beneficiaries | 52 |
| Number Of Non Hispanic White Beneficiaries | 99 |
| 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 | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 38 |
| Percent Of With Diabetes | 25 |
| Percent Of With Hyperlipidemia | 36 |
| Percent Of With Hypertension | 55 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.968 |