| National Provider Identifier [NPI]: | 1053330472 |
| Last Name Of The Provider | MONTAGUE |
| First Name Of The Provider | BRIAN |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 164 SUMMIT AVE |
| Street Address 2 Of The Provider | FAIN BLDG., SUITE E |
| City Of The Provider | PROVIDENCE |
| Zip Code Of The Provider | 029062853 |
| State Code Of The Provider | RI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 22 |
| Number Of Services | 248 |
| Number Of Medicare Beneficiaries | 68 |
| Total Submitted Charge Amount | 29299.27 |
| Total Medicare Allowed Amount | 19352.67 |
| Total Medicare Payment Amount | 13657.8 |
| Total Medicare Standardized Payment Amount | 13426.73 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 12 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 83.5 |
| Total Drug Medicare AllowedAmount | 23.48 |
| Total Drug Medicare PaymentAmount | 23.01 |
| Total Drug Medicare Standardized Payment Amount | 23.01 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 17 |
| Number Of Medical Services | 236 |
| Number Of Medicare Beneficiaries With Medical Services | 68 |
| Total Medical Submitted Charge Amount | 29215.77 |
| Total Medical Medicare Allowed Amount | 19329.19 |
| Total Medical Medicare Payment Amount | 13634.79 |
| Total Medical Medicare Standardized Payment Amount | 13403.72 |
| Average Age Of Beneficiaries | 55 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 20 |
| Number Of Male Beneficiaries | 48 |
| Number Of Non Hispanic White Beneficiaries | 43 |
| 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 | 17 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 51 |
| Percent Of With Atrial Fibrillation | 0 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 31 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 25 |
| Percent Of With Depression | 60 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 31 |
| Percent Of With Hypertension | 49 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | 0 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 22 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.2772 |