Olivia Grayce Tack, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

01062281A Issued in IN

Practice address

6913 N Main St Ste 200
Granger, IN 46530-8039

Phone

(574) 647-4540

Fax

(574) 647-2567

NPI assigned

Jun 7, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Olivia Grayce Fusillo Former name

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Pediatric Medicine

Education

Michigan State University College of Human Medicine, 2003

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Beacon Medical Group IncGroup PAC ID 1254243306, 575 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: tack@mybeacon.cernerdirect.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Beacon Medical Group, Inc.

  • Family Medicine Physician
  • Mishawaka, IN
  • NPI 1033161617
  Medicare reassignment Care Compare group NPD
• Beacon Medical Group Inc

  • Anesthesiology Physician
  • Elkhart, IN
  • NPI 1437803285
  NPD
• Beacon Medical Group, Inc.

  • Trauma Surgery Physician
  • South Bend, IN
  • NPI 1174927131
  NPD
• Beacon Medical Group, Inc.

  • Family Medicine Physician
  • South Bend, IN
  • NPI 1588024624
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149638400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1763942400000",
    "number": "1255371514",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3245 HEALTH DR STE 100",
            "city": "GRANGER",
            "state": "IN",
            "postal_code": "465301380",
            "telephone_number": "574-647-2713"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6913 N MAIN ST STE 200",
            "city": "GRANGER",
            "state": "IN",
            "postal_code": "465308039",
            "telephone_number": "574-647-4540",
            "fax_number": "574-647-2567"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TACK",
        "first_name": "OLIVIA",
        "middle_name": "GRAYCE",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-07",
        "last_updated": "2025-11-24",
        "certification_date": "2025-11-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "IN",
            "license": "01062281A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "247000031",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200828650",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "TACK@mybeacon.cernerdirect.com",
            "affiliation": "N",
            "address_1": "2235 Cleveland Rd",
            "city": "South Bend",
            "state": "IN",
            "country_code": "US",
            "postal_code": "466283529",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "OLIVIA",
            "last_name": "FUSILLO",
            "middle_name": "GRAYCE",
            "credential": "MD",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Surgical Services of Northern Indiana, LLC
• Tara Lynn Svatos, O.D.
• Tiffani Rene Swank, M.S., CCC-SLP
• Aileen M Sy, PT
• Toni Leigh Szabo
• Rachael Lynn Talbot, PT
• Tapia Enterprises, Inc.
• Kurt Allan Taulbee, LLP MASTERS
• Nicole Marie Taulbee, M.A., L.M.H.C., LPC
• Lisa Ann Walczak Thain, PHARMD

• Pediatrics Physician in Granger, IN
• Providers in Granger, IN by specialty
• Pediatrics Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.