Individual
OLIVIA GRAYCE TACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
6913 N MAIN ST STE 200, GRANGER, IN 46530-8039
(574) 647-4540
(574) 647-2567
Mailing address
3245 HEALTH DR STE 100, GRANGER, IN 46530-1380
(574) 647-2713
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
01062281A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200828650
—
IN
01
—
247000031
MEDICARE PTAN
IN
Enumeration date
06/07/2006
Last updated
11/24/2025
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