| National Provider Identifier [NPI]: | 1619194560 |
| Last Name Of The Provider | LEGOLVAN |
| First Name Of The Provider | MARK |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 593 EDDY ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | PROVIDENCE |
| Zip Code Of The Provider | 029034923 |
| State Code Of The Provider | RI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pathology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 2527 |
| Number Of Medicare Beneficiaries | 852 |
| Total Submitted Charge Amount | 434038.56 |
| Total Medicare Allowed Amount | 67643.12 |
| Total Medicare Payment Amount | 52245.12 |
| Total Medicare Standardized Payment Amount | 46103.15 |
| 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 | 31 |
| Number Of Medical Services | 2527 |
| Number Of Medicare Beneficiaries With Medical Services | 852 |
| Total Medical Submitted Charge Amount | 434038.56 |
| Total Medical Medicare Allowed Amount | 67643.12 |
| Total Medical Medicare Payment Amount | 52245.12 |
| Total Medical Medicare Standardized Payment Amount | 46103.15 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 172 |
| Number Of Beneficiaries Age 65 to 74 | 311 |
| Number Of Beneficiaries Age 75 to 84 | 257 |
| Number Of Beneficiaries Age Greater 84 | 112 |
| Number Of Female Beneficiaries | 480 |
| Number Of Male Beneficiaries | 372 |
| Number Of Non Hispanic White Beneficiaries | 671 |
| Number Of Black or African American Beneficiaries | 61 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 89 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 20 |
| Number Of Beneficiaries With Medicare Only Entitlement | 612 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 240 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 25 |
| Percent Of With Chronic Kidney Disease | 39 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 64 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.7214 |