| National Provider Identifier [NPI]: | 1033144084 |
| Last Name Of The Provider | COSTELLO |
| First Name Of The Provider | DOMINICA |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 155 BORTHWICK AVE |
| Street Address 2 Of The Provider | SUITE 301 |
| City Of The Provider | PORTSMOUTH |
| Zip Code Of The Provider | 038017156 |
| State Code Of The Provider | NH |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Endocrinology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 12 |
| Number Of Services | 1370 |
| Number Of Medicare Beneficiaries | 197 |
| Total Submitted Charge Amount | 147532 |
| Total Medicare Allowed Amount | 65873.15 |
| Total Medicare Payment Amount | 49841.14 |
| Total Medicare Standardized Payment Amount | 49088.69 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 900 |
| Number Of Medicare Beneficiaries With Drug Services | 14 |
| Total Drug Submitted ChargeAmount | 21975 |
| Total Drug Medicare AllowedAmount | 12977.16 |
| Total Drug Medicare PaymentAmount | 10174.08 |
| Total Drug Medicare Standardized Payment Amount | 10174.08 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 11 |
| Number Of Medical Services | 470 |
| Number Of Medicare Beneficiaries With Medical Services | 197 |
| Total Medical Submitted Charge Amount | 125557 |
| Total Medical Medicare Allowed Amount | 52895.99 |
| Total Medical Medicare Payment Amount | 39667.06 |
| Total Medical Medicare Standardized Payment Amount | 38914.61 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 46 |
| Number Of Beneficiaries Age 65 to 74 | 90 |
| Number Of Beneficiaries Age 75 to 84 | 45 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 127 |
| Number Of Male Beneficiaries | 70 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 155 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 42 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 30 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 34 |
| Percent Of With Diabetes | 56 |
| Percent Of With Hyperlipidemia | 70 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 18 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.4817 |