| National Provider Identifier [NPI]: | 1891011375 |
| Last Name Of The Provider | CICMANEC |
| First Name Of The Provider | SARA |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 389 S 900 E |
| Street Address 2 Of The Provider | INTERMOUNTAIN SALT LAKE CLINIC |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841022310 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 29 |
| Number Of Services | 1971 |
| Number Of Medicare Beneficiaries | 165 |
| Total Submitted Charge Amount | 67600 |
| Total Medicare Allowed Amount | 44760.6 |
| Total Medicare Payment Amount | 33473.19 |
| Total Medicare Standardized Payment Amount | 34711.36 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 1403 |
| Number Of Medicare Beneficiaries With Drug Services | 46 |
| Total Drug Submitted ChargeAmount | 12291 |
| Total Drug Medicare AllowedAmount | 7742.64 |
| Total Drug Medicare PaymentAmount | 6049.04 |
| Total Drug Medicare Standardized Payment Amount | 6049.04 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 568 |
| Number Of Medicare Beneficiaries With Medical Services | 165 |
| Total Medical Submitted Charge Amount | 55309 |
| Total Medical Medicare Allowed Amount | 37017.96 |
| Total Medical Medicare Payment Amount | 27424.15 |
| Total Medical Medicare Standardized Payment Amount | 28662.32 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 20 |
| Number Of Beneficiaries Age 65 to 74 | 51 |
| Number Of Beneficiaries Age 75 to 84 | 61 |
| Number Of Beneficiaries Age Greater 84 | 33 |
| Number Of Female Beneficiaries | 105 |
| Number Of Male Beneficiaries | 60 |
| 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 | 146 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | 19 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0711 |