| National Provider Identifier [NPI]: | 1669476123 |
| Last Name Of The Provider | WICKSTROM |
| First Name Of The Provider | KARL |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 790 GAIL GARDNER WAY |
| Street Address 2 Of The Provider | |
| City Of The Provider | PRESCOTT |
| Zip Code Of The Provider | 863052337 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 183 |
| Number Of Services | 19364 |
| Number Of Medicare Beneficiaries | 2347 |
| Total Submitted Charge Amount | 1260554.17 |
| Total Medicare Allowed Amount | 533853.45 |
| Total Medicare Payment Amount | 426535.55 |
| Total Medicare Standardized Payment Amount | 429770.66 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 15600 |
| Number Of Medicare Beneficiaries With Drug Services | 371 |
| Total Drug Submitted ChargeAmount | 30085 |
| Total Drug Medicare AllowedAmount | 8229.16 |
| Total Drug Medicare PaymentAmount | 6405.28 |
| Total Drug Medicare Standardized Payment Amount | 6405.28 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 179 |
| Number Of Medical Services | 3764 |
| Number Of Medicare Beneficiaries With Medical Services | 2346 |
| Total Medical Submitted Charge Amount | 1230469.17 |
| Total Medical Medicare Allowed Amount | 525624.29 |
| Total Medical Medicare Payment Amount | 420130.27 |
| Total Medical Medicare Standardized Payment Amount | 423365.38 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 158 |
| Number Of Beneficiaries Age 65 to 74 | 1268 |
| Number Of Beneficiaries Age 75 to 84 | 734 |
| Number Of Beneficiaries Age Greater 84 | 187 |
| Number Of Female Beneficiaries | 1607 |
| Number Of Male Beneficiaries | 740 |
| Number Of Non Hispanic White Beneficiaries | 2217 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 13 |
| Number Of Hispanic Beneficiaries | 72 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 29 |
| Number Of Beneficiaries With Medicare Only Entitlement | 2184 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 163 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 19 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 0.9306 |