| National Provider Identifier [NPI]: | 1043274368 |
| Last Name Of The Provider | IDICULLA |
| First Name Of The Provider | STANLEY |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | DPM |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 112 ELDEN ST |
| Street Address 2 Of The Provider | SUITE D |
| City Of The Provider | HERNDON |
| Zip Code Of The Provider | 201704874 |
| State Code Of The Provider | VA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Podiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 25 |
| Number Of Services | 494 |
| Number Of Medicare Beneficiaries | 79 |
| Total Submitted Charge Amount | 63255 |
| Total Medicare Allowed Amount | 31568.51 |
| Total Medicare Payment Amount | 24413.97 |
| Total Medicare Standardized Payment Amount | 21626.57 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 85 |
| Number Of Medicare Beneficiaries With Drug Services | 13 |
| Total Drug Submitted ChargeAmount | 1540 |
| Total Drug Medicare AllowedAmount | 98.26 |
| Total Drug Medicare PaymentAmount | 77.09 |
| Total Drug Medicare Standardized Payment Amount | 77.09 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 23 |
| Number Of Medical Services | 409 |
| Number Of Medicare Beneficiaries With Medical Services | 79 |
| Total Medical Submitted Charge Amount | 61715 |
| Total Medical Medicare Allowed Amount | 31470.25 |
| Total Medical Medicare Payment Amount | 24336.88 |
| Total Medical Medicare Standardized Payment Amount | 21549.48 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 41 |
| Number Of Beneficiaries Age 75 to 84 | 24 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 52 |
| Number Of Male Beneficiaries | 27 |
| Number Of Non Hispanic White Beneficiaries | 59 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 68 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 11 |
| 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 | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 49 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.99 |