Provider Demographics
NPI:1881641538
Name:CARIVEAU, THOMAS BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BRADLEY
Last Name:CARIVEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 BURBANK
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3712
Mailing Address - Country:US
Mailing Address - Phone:701-772-7758
Mailing Address - Fax:
Practice Address - Street 1:929 CENTRAL AVE NW
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1917
Practice Address - Country:US
Practice Address - Phone:218-773-6800
Practice Address - Fax:218-773-6861
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28494207Q00000X
ND5343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080161924OtherMEDICARE RAILROAD
0123578OtherMEDICA
MN044782000Medicaid
ND15307Medicaid
NA4571023344OtherPREFERRED ONE
MN512M2CAOtherBCBS
ND26521OtherBCBS
MN044782000Medicaid
MN080014836Medicare ID - Type Unspecified
P00303895Medicare ID - Type UnspecifiedRAILROAD
MN080016288Medicare PIN
D65010Medicare UPIN
0123578OtherMEDICA
MN080161924OtherMEDICARE RAILROAD