| National Provider Identifier [NPI]: | 1780878314 |
| Last Name Of The Provider | MORTENSEN |
| First Name Of The Provider | WAYNE |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 30 N 1900 E # 1A071 |
| Street Address 2 Of The Provider | UNIVERSITY OF UTAH DEPT OF RADIOLOGY |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841320002 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 162 |
| Number Of Services | 3645 |
| Number Of Medicare Beneficiaries | 2678 |
| Total Submitted Charge Amount | 363564.64 |
| Total Medicare Allowed Amount | 75481.47 |
| Total Medicare Payment Amount | 54910.21 |
| Total Medicare Standardized Payment Amount | 58758.48 |
| 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 | 162 |
| Number Of Medical Services | 3645 |
| Number Of Medicare Beneficiaries With Medical Services | 2678 |
| Total Medical Submitted Charge Amount | 363564.64 |
| Total Medical Medicare Allowed Amount | 75481.47 |
| Total Medical Medicare Payment Amount | 54910.21 |
| Total Medical Medicare Standardized Payment Amount | 58758.48 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 489 |
| Number Of Beneficiaries Age 65 to 74 | 1065 |
| Number Of Beneficiaries Age 75 to 84 | 754 |
| Number Of Beneficiaries Age Greater 84 | 370 |
| Number Of Female Beneficiaries | 1638 |
| Number Of Male Beneficiaries | 1040 |
| Number Of Non Hispanic White Beneficiaries | 2504 |
| Number Of Black or African American Beneficiaries | 15 |
| Number Of AsianPacific Islander Beneficiaries | 21 |
| Number Of Hispanic Beneficiaries | 100 |
| Number Of American Indian Alaska Native Beneficiaries | 11 |
| Number Of Beneficiaries With Race Not Else where Classified | 27 |
| Number Of Beneficiaries With Medicare Only Entitlement | 2135 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 543 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 54 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.3487 |