| National Provider Identifier [NPI]: | 1689842007 |
| Last Name Of The Provider | GUSTAFSON |
| First Name Of The Provider | HOLLY |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 701 PARK AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | MINNEAPOLIS |
| Zip Code Of The Provider | 554151623 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 63 |
| Number Of Services | 1120 |
| Number Of Medicare Beneficiaries | 130 |
| Total Submitted Charge Amount | 86388.44 |
| Total Medicare Allowed Amount | 37420.41 |
| Total Medicare Payment Amount | 28047.6 |
| Total Medicare Standardized Payment Amount | 28835.25 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 88 |
| Number Of Medicare Beneficiaries With Drug Services | 38 |
| Total Drug Submitted ChargeAmount | 3553 |
| Total Drug Medicare AllowedAmount | 2248.67 |
| Total Drug Medicare PaymentAmount | 2187 |
| Total Drug Medicare Standardized Payment Amount | 2187 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 58 |
| Number Of Medical Services | 1032 |
| Number Of Medicare Beneficiaries With Medical Services | 130 |
| Total Medical Submitted Charge Amount | 82835.44 |
| Total Medical Medicare Allowed Amount | 35171.74 |
| Total Medical Medicare Payment Amount | 25860.6 |
| Total Medical Medicare Standardized Payment Amount | 26648.25 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 26 |
| Number Of Beneficiaries Age 65 to 74 | 42 |
| Number Of Beneficiaries Age 75 to 84 | 40 |
| Number Of Beneficiaries Age Greater 84 | 22 |
| Number Of Female Beneficiaries | 96 |
| Number Of Male Beneficiaries | 34 |
| Number Of Non Hispanic White Beneficiaries | 117 |
| 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 | 101 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 29 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 12 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 18 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 49 |
| Percent Of With Ischemic Heart Disease | 15 |
| Percent Of With Osteoporosis | 14 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2492 |