Healthcare Provider Details

I. General information

NPI: 1710744792
Provider Name (Legal Business Name): CAPITAL MEDICAL CENTER PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E BROADWAY AVE
MONTESANO WA
98563-3704
US

IV. Provider business mailing address

P.O. BOX 5299 MS: 820-5-PCO
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-4111
  • Fax: 360-249-5220
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM GLENN ROBERTSON
Title or Position: CEO
Credential:
Phone: 253-403-1272