| National Provider Identifier [NPI]: | 1922238823 |
| Last Name Of The Provider | LICK |
| First Name Of The Provider | SIMON |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3705 13TH AVE S |
| Street Address 2 Of The Provider | |
| City Of The Provider | MINNEAPOLIS |
| Zip Code Of The Provider | 554072709 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 25 |
| Number Of Services | 481 |
| Number Of Medicare Beneficiaries | 163 |
| Total Submitted Charge Amount | 139223.49 |
| Total Medicare Allowed Amount | 53637.73 |
| Total Medicare Payment Amount | 41952.9 |
| Total Medicare Standardized Payment Amount | 43068.03 |
| 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 | 25 |
| Number Of Medical Services | 481 |
| Number Of Medicare Beneficiaries With Medical Services | 163 |
| Total Medical Submitted Charge Amount | 139223.49 |
| Total Medical Medicare Allowed Amount | 53637.73 |
| Total Medical Medicare Payment Amount | 41952.9 |
| Total Medical Medicare Standardized Payment Amount | 43068.03 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 26 |
| Number Of Beneficiaries Age 65 to 74 | 39 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 46 |
| Number Of Female Beneficiaries | 86 |
| Number Of Male Beneficiaries | 77 |
| 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 | 119 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 44 |
| Percent Of With Atrial Fibrillation | 28 |
| Percent Of With Alzheimers Disease or Dementia | 17 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 43 |
| Percent Of With Chronic Kidney Disease | 47 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 36 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.8136 |