| National Provider Identifier [NPI]: | 1770587693 |
| Last Name Of The Provider | DOMINGO |
| First Name Of The Provider | EVILLO |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 21 W MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | SHILOH |
| Zip Code Of The Provider | 448789732 |
| State Code Of The Provider | OH |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 795 |
| Number Of Medicare Beneficiaries | 201 |
| Total Submitted Charge Amount | 89608 |
| Total Medicare Allowed Amount | 58769.52 |
| Total Medicare Payment Amount | 39317.32 |
| Total Medicare Standardized Payment Amount | 40950.86 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 41 |
| Number Of Medicare Beneficiaries With Drug Services | 34 |
| Total Drug Submitted ChargeAmount | 2006 |
| Total Drug Medicare AllowedAmount | 1018.46 |
| Total Drug Medicare PaymentAmount | 995.6 |
| Total Drug Medicare Standardized Payment Amount | 995.6 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 26 |
| Number Of Medical Services | 754 |
| Number Of Medicare Beneficiaries With Medical Services | 201 |
| Total Medical Submitted Charge Amount | 87602 |
| Total Medical Medicare Allowed Amount | 57751.06 |
| Total Medical Medicare Payment Amount | 38321.72 |
| Total Medical Medicare Standardized Payment Amount | 39955.26 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 46 |
| Number Of Beneficiaries Age 65 to 74 | 77 |
| Number Of Beneficiaries Age 75 to 84 | 46 |
| Number Of Beneficiaries Age Greater 84 | 32 |
| Number Of Female Beneficiaries | 107 |
| Number Of Male Beneficiaries | 94 |
| 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 | 136 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 65 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 18 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 25 |
| Percent Of With Chronic Kidney Disease | 27 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 26 |
| Percent Of With Depression | 30 |
| Percent Of With Diabetes | 43 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 41 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 9 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.3518 |