| National Provider Identifier [NPI]: | 1700103587 |
| Last Name Of The Provider | KIMBALL |
| First Name Of The Provider | MARILYN |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | LCSW |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 474 MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | SPRINGVALE |
| Zip Code Of The Provider | 040831409 |
| State Code Of The Provider | ME |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Licensed Clinical Social Worker |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 3 |
| Number Of Services | 1131 |
| Number Of Medicare Beneficiaries | 83 |
| Total Submitted Charge Amount | 113266.69 |
| Total Medicare Allowed Amount | 106624.07 |
| Total Medicare Payment Amount | 80144.07 |
| Total Medicare Standardized Payment Amount | 81927.47 |
| 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 | 3 |
| Number Of Medical Services | 1131 |
| Number Of Medicare Beneficiaries With Medical Services | 83 |
| Total Medical Submitted Charge Amount | 113266.69 |
| Total Medical Medicare Allowed Amount | 106624.07 |
| Total Medical Medicare Payment Amount | 80144.07 |
| Total Medical Medicare Standardized Payment Amount | 81927.47 |
| Average Age Of Beneficiaries | 53 |
| Number Of Beneficiaries Age Less65 | 64 |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 64 |
| Number Of Male Beneficiaries | 19 |
| 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 | 13 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 70 |
| Percent Of With Atrial Fibrillation | 0 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 16 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 75 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 36 |
| Percent Of With Hypertension | 39 |
| Percent Of With Ischemic Heart Disease | 14 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 14 |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 1.3628 |