| National Provider Identifier [NPI]: | 1295877702 |
| Last Name Of The Provider | DIETZ |
| First Name Of The Provider | KELLY |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 516 DELAWARE STREET SE |
| Street Address 2 Of The Provider | UMPHYSICIANS IMAGING CENTER |
| City Of The Provider | MINNEAPOLIS |
| Zip Code Of The Provider | 554550341 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 42 |
| Number Of Services | 219 |
| Number Of Medicare Beneficiaries | 172 |
| Total Submitted Charge Amount | 32332 |
| Total Medicare Allowed Amount | 7285.47 |
| Total Medicare Payment Amount | 5779.71 |
| Total Medicare Standardized Payment Amount | 6048 |
| 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 | 42 |
| Number Of Medical Services | 219 |
| Number Of Medicare Beneficiaries With Medical Services | 172 |
| Total Medical Submitted Charge Amount | 32332 |
| Total Medical Medicare Allowed Amount | 7285.47 |
| Total Medical Medicare Payment Amount | 5779.71 |
| Total Medical Medicare Standardized Payment Amount | 6048 |
| Average Age Of Beneficiaries | 59 |
| Number Of Beneficiaries Age Less65 | 89 |
| Number Of Beneficiaries Age 65 to 74 | 56 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 112 |
| Number Of Male Beneficiaries | 60 |
| Number Of Non Hispanic White Beneficiaries | 133 |
| Number Of Black or African American Beneficiaries | 24 |
| 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 | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 87 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 85 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 41 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 35 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 33 |
| Percent Of With Hypertension | 53 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | 17 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.1989 |