| National Provider Identifier [NPI]: | 1528173846 |
| Last Name Of The Provider | KINCANNON |
| First Name Of The Provider | LEROY |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | O.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1542 GOLF COURSE RD |
| Street Address 2 Of The Provider | SUITE 201 |
| City Of The Provider | GRAND RAPIDS |
| Zip Code Of The Provider | 557449603 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Optometry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 22 |
| Number Of Services | 553 |
| Number Of Medicare Beneficiaries | 474 |
| Total Submitted Charge Amount | 63530.4 |
| Total Medicare Allowed Amount | 57185.18 |
| Total Medicare Payment Amount | 35260.76 |
| Total Medicare Standardized Payment Amount | 35855.45 |
| 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 | 22 |
| Number Of Medical Services | 553 |
| Number Of Medicare Beneficiaries With Medical Services | 474 |
| Total Medical Submitted Charge Amount | 63530.4 |
| Total Medical Medicare Allowed Amount | 57185.18 |
| Total Medical Medicare Payment Amount | 35260.76 |
| Total Medical Medicare Standardized Payment Amount | 35855.45 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 99 |
| Number Of Beneficiaries Age 65 to 74 | 173 |
| Number Of Beneficiaries Age 75 to 84 | 130 |
| Number Of Beneficiaries Age Greater 84 | 72 |
| Number Of Female Beneficiaries | 262 |
| Number Of Male Beneficiaries | 212 |
| Number Of Non Hispanic White Beneficiaries | 451 |
| 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 | 355 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 119 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 39 |
| Percent Of With Hypertension | 51 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 4 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.0479 |