| National Provider Identifier [NPI]: | 1790797959 |
| Last Name Of The Provider | BANK |
| First Name Of The Provider | STACEY |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4465 S 900 E |
| Street Address 2 Of The Provider | SUITE 200 |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841242456 |
| 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 | 36 |
| Number Of Services | 981 |
| Number Of Medicare Beneficiaries | 189 |
| Total Submitted Charge Amount | 130939 |
| Total Medicare Allowed Amount | 61955.58 |
| Total Medicare Payment Amount | 44545.74 |
| Total Medicare Standardized Payment Amount | 46927.71 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 107 |
| Number Of Medicare Beneficiaries With Drug Services | 71 |
| Total Drug Submitted ChargeAmount | 6444 |
| Total Drug Medicare AllowedAmount | 2544.21 |
| Total Drug Medicare PaymentAmount | 2467.24 |
| Total Drug Medicare Standardized Payment Amount | 2467.24 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 29 |
| Number Of Medical Services | 874 |
| Number Of Medicare Beneficiaries With Medical Services | 189 |
| Total Medical Submitted Charge Amount | 124495 |
| Total Medical Medicare Allowed Amount | 59411.37 |
| Total Medical Medicare Payment Amount | 42078.5 |
| Total Medical Medicare Standardized Payment Amount | 44460.47 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 18 |
| Number Of Beneficiaries Age 65 to 74 | 91 |
| Number Of Beneficiaries Age 75 to 84 | 57 |
| Number Of Beneficiaries Age Greater 84 | 23 |
| Number Of Female Beneficiaries | 144 |
| Number Of Male Beneficiaries | 45 |
| Number Of Non Hispanic White Beneficiaries | 171 |
| Number Of Black or African American Beneficiaries | |
| 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 | 172 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 17 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 20 |
| Percent Of With Hyperlipidemia | 37 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 19 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8825 |