| National Provider Identifier [NPI]: | 1144240623 |
| Last Name Of The Provider | SHANE |
| First Name Of The Provider | CRAIG |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 8TH AVE C ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841430001 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Emergency Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 547 |
| Number Of Medicare Beneficiaries | 331 |
| Total Submitted Charge Amount | 156212.57 |
| Total Medicare Allowed Amount | 53835.96 |
| Total Medicare Payment Amount | 39421.15 |
| Total Medicare Standardized Payment Amount | 40866.59 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 547 |
| Number Of Medicare Beneficiaries With Medical Services | 331 |
| Total Medical Submitted Charge Amount | 156212.57 |
| Total Medical Medicare Allowed Amount | 53835.96 |
| Total Medical Medicare Payment Amount | 39421.15 |
| Total Medical Medicare Standardized Payment Amount | 40866.59 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 94 |
| Number Of Beneficiaries Age 65 to 74 | 82 |
| Number Of Beneficiaries Age 75 to 84 | 99 |
| Number Of Beneficiaries Age Greater 84 | 56 |
| Number Of Female Beneficiaries | 195 |
| Number Of Male Beneficiaries | 136 |
| Number Of Non Hispanic White Beneficiaries | 284 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 28 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 248 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 83 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 37 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 39 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 47 |
| Percent Of With Hypertension | 69 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.7127 |