MEDICARE: ENDURANCE SPORTS MEDICINE, 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	208000000X	Pediatrics Physician	25MA08329600	NJ
2	2080S0010X	Pediatric Sports Medicine Physician	25MA08329600	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	25MA08329600	OTHER	NJ	MEDICAL LIC
2	D09206900	OTHER	NJ	CDS

General Provider Information

NPI Number	:	1740516897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENDURANCE SPORTS MEDICINE, LLC

Provider Business Mailing Address
First Line	:	1230 WHITEHORSE MERCERVILLE RD
Second Line	:
City	:	HAMILTON
State	:	NJ
Zip	:	08619-3814
Country	:	US
Telephone Number	:	609-581-1700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1230 WHITEHORSE MERCERVILLE RD
Second Line	:
City	:	HAMILTON
State	:	NJ
Zip	:	08619-3814
Country	:	US
Telephone Number	:	609-581-1700
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. CHARLES E FLORES
Credential	:	M.D.
Telephone Number	:	609-581-1700

Provider Enumeration Date	:	10/26/2009
Last Update Date	:	03/07/2023

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