Provider Demographics
NPI:1255371514
Name:TACK, OLIVIA GRAYCE (MD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRAYCE
Last Name:TACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:GRAYCE
Other - Last Name:FUSILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:2235 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3529
Practice Address - Country:US
Practice Address - Phone:574-647-4530
Practice Address - Fax:574-647-2285
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062281A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN247000031OtherMEDICARE PTAN
IN200828650Medicaid