MEDICARE: CAPITAL MEDICAL CENTER PHYSICIANS LLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1710744792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL MEDICAL CENTER PHYSICIANS LLC

Provider Business Mailing Address
First Line	:	P.O. BOX 5299
Second Line	:	MS: 820-5-PCO
City	:	TACOMA
State	:	WA
Zip	:	98415-0299
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 E BROADWAY AVE
Second Line	:
City	:	MONTESANO
State	:	WA
Zip	:	98563-3704
Country	:	US
Telephone Number	:	360-249-4111
Fax Number	:	360-249-5220

Authorized Official
Title or Position	:	CEO
Name	:	WILLIAM GLENN ROBERTSON
Credential	:
Telephone Number	:	253-403-1272

Provider Enumeration Date	:	03/05/2024
Last Update Date	:	08/04/2025

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