| National Provider Identifier [NPI]: | 1932420809 |
| Last Name Of The Provider | PROVOST |
| First Name Of The Provider | BRIDGETTE |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3708 MOUNTAIN RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | PASADENA |
| Zip Code Of The Provider | 211222025 |
| State Code Of The Provider | MD |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 25 |
| Number Of Services | 823 |
| Number Of Medicare Beneficiaries | 339 |
| Total Submitted Charge Amount | 176946 |
| Total Medicare Allowed Amount | 88562 |
| Total Medicare Payment Amount | 62703.35 |
| Total Medicare Standardized Payment Amount | 58956.66 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 25 |
| Number Of Medicare Beneficiaries With Drug Services | 22 |
| Total Drug Submitted ChargeAmount | 940 |
| Total Drug Medicare AllowedAmount | 631.03 |
| Total Drug Medicare PaymentAmount | 613.69 |
| Total Drug Medicare Standardized Payment Amount | 613.69 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 20 |
| Number Of Medical Services | 798 |
| Number Of Medicare Beneficiaries With Medical Services | 339 |
| Total Medical Submitted Charge Amount | 176006 |
| Total Medical Medicare Allowed Amount | 87930.97 |
| Total Medical Medicare Payment Amount | 62089.66 |
| Total Medical Medicare Standardized Payment Amount | 58342.97 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 40 |
| Number Of Beneficiaries Age 65 to 74 | 150 |
| Number Of Beneficiaries Age 75 to 84 | 109 |
| Number Of Beneficiaries Age Greater 84 | 40 |
| Number Of Female Beneficiaries | 194 |
| Number Of Male Beneficiaries | 145 |
| Number Of Non Hispanic White Beneficiaries | 319 |
| 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 | 315 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 24 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 22 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 23 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 75 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.0753 |