| National Provider Identifier [NPI]: | 1568497659 |
| Last Name Of The Provider | COLLYMORE |
| First Name Of The Provider | DACOSTA |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | RPT |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 5000 OVERLAND AVE STE 4 |
| Street Address 2 Of The Provider | |
| City Of The Provider | CULVER CITY |
| Zip Code Of The Provider | 902304995 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physical Therapist |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 5 |
| Number Of Services | 3662 |
| Number Of Medicare Beneficiaries | 62 |
| Total Submitted Charge Amount | 116445 |
| Total Medicare Allowed Amount | 90408.54 |
| Total Medicare Payment Amount | 69639.24 |
| Total Medicare Standardized Payment Amount | 58696.56 |
| 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 | 5 |
| Number Of Medical Services | 3662 |
| Number Of Medicare Beneficiaries With Medical Services | 62 |
| Total Medical Submitted Charge Amount | 116445 |
| Total Medical Medicare Allowed Amount | 90408.54 |
| Total Medical Medicare Payment Amount | 69639.24 |
| Total Medical Medicare Standardized Payment Amount | 58696.56 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 29 |
| Number Of Beneficiaries Age 75 to 84 | 18 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 45 |
| Number Of Male Beneficiaries | 17 |
| Number Of Non Hispanic White Beneficiaries | 28 |
| Number Of Black or African American Beneficiaries | 17 |
| 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 | 37 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 25 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 18 |
| Percent Of With Chronic Kidney Disease | 27 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 40 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2993 |