Individual ProviderJack A. RothThoracic Surgery (Cardiothoracic Vascular Surgery)Allopathic & Osteopathic PhysiciansPractice Address1515 Holcombe Blvd, Houston, TX 77030-4009(713) 792-6161(713) 792-2991PECOS EnrollmentBased on the most recent information from CMS, provider Jack A. Roth does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1245336320Provider TypeIndividualFull NameRoth, Jack A.CredentialM.D.GenderMaleSole ProprietorNoEnumeration Date9/15/2006Last Updated2/24/2011Contact InformationPractice LocationPractice Address1515 Holcombe Blvd, Houston, TX 77030-4009Phone(713) 792-6161FaxUnlisted FaxMailing LocationMailing AddressPO Box 4439, Houston, TX 77210-4439Phone(713) 792-2991FaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode208G00000XPrimaryDescriptionThoracic Surgery (Cardiothoracic Vascular Surgery)Allopathic & Osteopathic PhysiciansLicenseH1200TexasProvider IdentifiersIDDescriptionIssuerID330002394DescriptionOtherIssuerRR MCRTexasID800866DescriptionOtherIssuerBCBSTexasID036709601DescriptionMedicaidIssuerUnlistedTexas