| National Provider Identifier [NPI]: | 1538172523 |
| Last Name Of The Provider | LICATA |
| First Name Of The Provider | CHARLES |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 625 CLARK AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | BRISTOL |
| Zip Code Of The Provider | 060104068 |
| State Code Of The Provider | CT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 96 |
| Number Of Services | 4211 |
| Number Of Medicare Beneficiaries | 337 |
| Total Submitted Charge Amount | 319097 |
| Total Medicare Allowed Amount | 179747.87 |
| Total Medicare Payment Amount | 139565.16 |
| Total Medicare Standardized Payment Amount | 131956.84 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 184 |
| Number Of Medicare Beneficiaries With Drug Services | 131 |
| Total Drug Submitted ChargeAmount | 6492 |
| Total Drug Medicare AllowedAmount | 5134.01 |
| Total Drug Medicare PaymentAmount | 4867.05 |
| Total Drug Medicare Standardized Payment Amount | 4867.05 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 90 |
| Number Of Medical Services | 4027 |
| Number Of Medicare Beneficiaries With Medical Services | 337 |
| Total Medical Submitted Charge Amount | 312605 |
| Total Medical Medicare Allowed Amount | 174613.86 |
| Total Medical Medicare Payment Amount | 134698.11 |
| Total Medical Medicare Standardized Payment Amount | 127089.79 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 42 |
| Number Of Beneficiaries Age 65 to 74 | 119 |
| Number Of Beneficiaries Age 75 to 84 | 94 |
| Number Of Beneficiaries Age Greater 84 | 82 |
| Number Of Female Beneficiaries | 212 |
| Number Of Male Beneficiaries | 125 |
| Number Of Non Hispanic White Beneficiaries | 319 |
| 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 | 223 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 114 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 23 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 72 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 28 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.3041 |