| National Provider Identifier [NPI]: | 1346467941 |
| Last Name Of The Provider | MONTALVO |
| First Name Of The Provider | JESSICA |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | MCGAW MEDICAL CENTER-NORTHWESTERN UNIVERSITY |
| Street Address 2 Of The Provider | 201 E HURON, GALTER 3-150 |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 60611 |
| 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 | 14 |
| Number Of Services | 389 |
| Number Of Medicare Beneficiaries | 215 |
| Total Submitted Charge Amount | 118430 |
| Total Medicare Allowed Amount | 40573.12 |
| Total Medicare Payment Amount | 31536.98 |
| Total Medicare Standardized Payment Amount | 29374.41 |
| 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 | 14 |
| Number Of Medical Services | 389 |
| Number Of Medicare Beneficiaries With Medical Services | 215 |
| Total Medical Submitted Charge Amount | 118430 |
| Total Medical Medicare Allowed Amount | 40573.12 |
| Total Medical Medicare Payment Amount | 31536.98 |
| Total Medical Medicare Standardized Payment Amount | 29374.41 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 41 |
| Number Of Beneficiaries Age 65 to 74 | 77 |
| Number Of Beneficiaries Age 75 to 84 | 49 |
| Number Of Beneficiaries Age Greater 84 | 48 |
| Number Of Female Beneficiaries | 115 |
| Number Of Male Beneficiaries | 100 |
| Number Of Non Hispanic White Beneficiaries | 137 |
| Number Of Black or African American Beneficiaries | 52 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 15 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 148 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 67 |
| Percent Of With Atrial Fibrillation | 27 |
| Percent Of With Alzheimers Disease or Dementia | 24 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 35 |
| Percent Of With Heart Failure | 46 |
| Percent Of With Chronic Kidney Disease | 74 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 32 |
| Percent Of With Depression | 41 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 55 |
| Percent Of With Osteoporosis | 13 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 47 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | 19 |
| Average HCC Risk Score Of Beneficiaries | 3.0421 |