Provider Demographics
NPI:1598752966
Name:NOVERO, WALLY N (MD)
Entity Type:Individual
Prefix:
First Name:WALLY
Middle Name:N
Last Name:NOVERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 HERMITAGE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148
Mailing Address - Country:US
Mailing Address - Phone:724-977-2501
Mailing Address - Fax:
Practice Address - Street 1:2375 GARDEN WAY
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148
Practice Address - Country:US
Practice Address - Phone:724-983-5454
Practice Address - Fax:724-983-5401
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4254542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012083480001Medicaid
PA1687402OtherHIGHMARK
PA1012083480001Medicaid
PA088674Medicare ID - Type Unspecified