| National Provider Identifier [NPI]: | 1669812111 |
| Last Name Of The Provider | FIACK |
| First Name Of The Provider | KELLY |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | CRNA |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 489 STATE ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | BANGOR |
| Zip Code Of The Provider | 044016616 |
| State Code Of The Provider | ME |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | CRNA |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 61 |
| Number Of Services | 547 |
| Number Of Medicare Beneficiaries | 508 |
| Total Submitted Charge Amount | 396133.67 |
| Total Medicare Allowed Amount | 71471.13 |
| Total Medicare Payment Amount | 55824.76 |
| Total Medicare Standardized Payment Amount | 58456.89 |
| 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 | 61 |
| Number Of Medical Services | 547 |
| Number Of Medicare Beneficiaries With Medical Services | 508 |
| Total Medical Submitted Charge Amount | 396133.67 |
| Total Medical Medicare Allowed Amount | 71471.13 |
| Total Medical Medicare Payment Amount | 55824.76 |
| Total Medical Medicare Standardized Payment Amount | 58456.89 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 100 |
| Number Of Beneficiaries Age 65 to 74 | 198 |
| Number Of Beneficiaries Age 75 to 84 | 154 |
| Number Of Beneficiaries Age Greater 84 | 56 |
| Number Of Female Beneficiaries | 289 |
| Number Of Male Beneficiaries | 219 |
| Number Of Non Hispanic White Beneficiaries | 491 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| 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 | 282 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 226 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 24 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 31 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 69 |
| Percent Of With Ischemic Heart Disease | 40 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.5073 |