| National Provider Identifier [NPI]: | 1124031174 |
| Last Name Of The Provider | DOMINIQUE |
| First Name Of The Provider | MARIE |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | PA |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2434 W BELVEDERE AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | BALTIMORE |
| Zip Code Of The Provider | 212155202 |
| State Code Of The Provider | MD |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 13 |
| Number Of Services | 424 |
| Number Of Medicare Beneficiaries | 359 |
| Total Submitted Charge Amount | 54825 |
| Total Medicare Allowed Amount | 36401.98 |
| Total Medicare Payment Amount | 28456.12 |
| Total Medicare Standardized Payment Amount | 32087.4 |
| 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 | 13 |
| Number Of Medical Services | 424 |
| Number Of Medicare Beneficiaries With Medical Services | 359 |
| Total Medical Submitted Charge Amount | 54825 |
| Total Medical Medicare Allowed Amount | 36401.98 |
| Total Medical Medicare Payment Amount | 28456.12 |
| Total Medical Medicare Standardized Payment Amount | 32087.4 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 49 |
| Number Of Beneficiaries Age 65 to 74 | 92 |
| Number Of Beneficiaries Age 75 to 84 | 136 |
| Number Of Beneficiaries Age Greater 84 | 82 |
| Number Of Female Beneficiaries | 213 |
| Number Of Male Beneficiaries | 146 |
| Number Of Non Hispanic White Beneficiaries | 214 |
| Number Of Black or African American Beneficiaries | 132 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 224 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 135 |
| Percent Of With Atrial Fibrillation | 25 |
| Percent Of With Alzheimers Disease or Dementia | 75 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 48 |
| Percent Of With Chronic Kidney Disease | 57 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 32 |
| Percent Of With Depression | 74 |
| Percent Of With Diabetes | 45 |
| Percent Of With Hyperlipidemia | 67 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 67 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 50 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 53 |
| Percent Of With Stroke | 25 |
| Average HCC Risk Score Of Beneficiaries | 2.6652 |