MEDICARE: WEST AVE PLASTIC SURGERY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	P1585	TX

General Provider Information

NPI Number	:	1386913317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST AVE PLASTIC SURGERY, PA

Provider Business Mailing Address
First Line	:	2800 KIRBY DR
Second Line	:	B212
City	:	HOUSTON
State	:	TX
Zip	:	77098
Country	:	US
Telephone Number	:	713-559-9300
Fax Number	:	888-878-1489

Provider Business Practice Location Address
First Line	:	2800 KIRBY DR
Second Line	:	B212
City	:	HOUSTON
State	:	TX
Zip	:	77098-1273
Country	:	US
Telephone Number	:	713-591-0283
Fax Number	:	888-878-1489

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FORREST SUSSMAN ROTH
Credential	:	M.D.
Telephone Number	:	713-591-9283

Provider Enumeration Date	:	12/20/2011
Last Update Date	:	05/09/2012

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