MEDICARE: RICHMOND BEHAVIORAL WELLNESS PHYSICIAN PLLC

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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1598583494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHMOND BEHAVIORAL WELLNESS PHYSICIAN PLLC

Provider Business Mailing Address
First Line	:	260 CHRISTOPHER LN STE 3F
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1607
Country	:	US
Telephone Number	:	718-317-5522
Fax Number	:	718-494-5714

Provider Business Practice Location Address
First Line	:	260 CHRISTOPHER LN STE 3F
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1607
Country	:	US
Telephone Number	:	718-317-5522
Fax Number	:	718-494-5714

Authorized Official
Title or Position	:	OWNER
Name	:	MARK DIBUONO
Credential	:	MD
Telephone Number	:	718-317-5522

Provider Enumeration Date	:	09/30/2024
Last Update Date	:	09/30/2024

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