| National Provider Identifier [NPI]: | 1083782197 |
| Last Name Of The Provider | VIDAL |
| First Name Of The Provider | MARIEBERTA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1515 HOLCOMBE BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | HOUSTON |
| Zip Code Of The Provider | 770304009 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 12 |
| Number Of Services | 398 |
| Number Of Medicare Beneficiaries | 256 |
| Total Submitted Charge Amount | 139309 |
| Total Medicare Allowed Amount | 47400.07 |
| Total Medicare Payment Amount | 36729.02 |
| Total Medicare Standardized Payment Amount | 37196.46 |
| 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 | 12 |
| Number Of Medical Services | 398 |
| Number Of Medicare Beneficiaries With Medical Services | 256 |
| Total Medical Submitted Charge Amount | 139309 |
| Total Medical Medicare Allowed Amount | 47400.07 |
| Total Medical Medicare Payment Amount | 36729.02 |
| Total Medical Medicare Standardized Payment Amount | 37196.46 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 57 |
| Number Of Beneficiaries Age 65 to 74 | 126 |
| Number Of Beneficiaries Age 75 to 84 | 58 |
| Number Of Beneficiaries Age Greater 84 | 15 |
| Number Of Female Beneficiaries | 131 |
| Number Of Male Beneficiaries | 125 |
| Number Of Non Hispanic White Beneficiaries | 165 |
| Number Of Black or African American Beneficiaries | 36 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 39 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 200 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 56 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 53 |
| Percent Of With Heart Failure | 27 |
| Percent Of With Chronic Kidney Disease | 44 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 26 |
| Percent Of With Depression | 45 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 45 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 2.9051 |