| National Provider Identifier [NPI]: | 1912169764 |
| Last Name Of The Provider | PROVIAS |
| First Name Of The Provider | TIM |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 675 N SAINT CLAIR ST |
| Street Address 2 Of The Provider | GALTER 19-100 |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606115975 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 42 |
| Number Of Services | 473 |
| Number Of Medicare Beneficiaries | 181 |
| Total Submitted Charge Amount | 185921 |
| Total Medicare Allowed Amount | 49707.12 |
| Total Medicare Payment Amount | 38974.34 |
| Total Medicare Standardized Payment Amount | 36004.6 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 37 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 9765 |
| Total Drug Medicare AllowedAmount | 1992.49 |
| Total Drug Medicare PaymentAmount | 1562.1 |
| Total Drug Medicare Standardized Payment Amount | 1562.1 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 40 |
| Number Of Medical Services | 436 |
| Number Of Medicare Beneficiaries With Medical Services | 180 |
| Total Medical Submitted Charge Amount | 176156 |
| Total Medical Medicare Allowed Amount | 47714.63 |
| Total Medical Medicare Payment Amount | 37412.24 |
| Total Medical Medicare Standardized Payment Amount | 34442.5 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 24 |
| Number Of Beneficiaries Age 65 to 74 | 59 |
| Number Of Beneficiaries Age 75 to 84 | 56 |
| Number Of Beneficiaries Age Greater 84 | 42 |
| Number Of Female Beneficiaries | 89 |
| Number Of Male Beneficiaries | 92 |
| Number Of Non Hispanic White Beneficiaries | 115 |
| Number Of Black or African American Beneficiaries | 24 |
| Number Of AsianPacific Islander Beneficiaries | 18 |
| 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 | 128 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 53 |
| Percent Of With Atrial Fibrillation | 30 |
| Percent Of With Alzheimers Disease or Dementia | 20 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 40 |
| Percent Of With Chronic Kidney Disease | 48 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 70 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 61 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 48 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 11 |
| Average HCC Risk Score Of Beneficiaries | 1.8737 |