Provider Demographics
NPI:1578620621
Name:TACK, RALPH WILLIAM (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:WILLIAM
Last Name:TACK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3200
Mailing Address - Country:US
Mailing Address - Phone:419-333-2738
Mailing Address - Fax:419-333-6416
Practice Address - Street 1:715 S TAFT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3200
Practice Address - Country:US
Practice Address - Phone:419-333-2738
Practice Address - Fax:419-333-6416
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350480412083P0500X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35048041OtherMEDICAL LICENSE
OH35048041OtherMEDICAL LICENSE
L60246Medicare ID - Type Unspecified