Healthcare Provider Details

I. General information

NPI: 1407668908
Provider Name (Legal Business Name): PATRIOTMED OF NORTH CAROLINA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 BENTRIDGE LN STE 400
FAYETTEVILLE NC
28304-0590
US

IV. Provider business mailing address

22601 N 19TH AVE
PHOENIX AZ
85027-1326
US

V. Phone/Fax

Practice location:
  • Phone: 480-369-1270
  • Fax:
Mailing address:
  • Phone: 480-369-1270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT SCOTT THORNOCK
Title or Position: CHIEF STRATEGY OFFICER
Credential:
Phone: 480-369-1270