Healthcare Provider Details

I. General information

NPI: 1104505965
Provider Name (Legal Business Name): BAILEY STEWART BERELSMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N WABASH AVE
MARION IN
46952-2612
US

IV. Provider business mailing address

11963 TURTLE CREEK CT
FORT WAYNE IN
46818-8572
US

V. Phone/Fax

Practice location:
  • Phone: 765-665-6020
  • Fax: 765-665-6020
Mailing address:
  • Phone: 571-453-1059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26030355A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: