Basic Information
| Provider Information | |||||||||
| NPI: | 1598752966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOVERO | ||||||||
| FirstName: | WALLY | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 HERMITAGE HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249772501 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2375 GARDEN WAY | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249835454 | ||||||||
| FaxNumber: | 7249835401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD425454 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1012083480001 | 05 | PA | MEDICAID | 1687402 | 01 | PA | HIGHMARK | OTHER |