Provider Demographics
NPI:1780803098
Name:BUCKTHAL-MCCUIN, JILL (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:BUCKTHAL-MCCUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 NEWNAN CROSSING BYP
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-2384
Mailing Address - Country:US
Mailing Address - Phone:770-251-5111
Mailing Address - Fax:770-254-8680
Practice Address - Street 1:1000 COWLES CLINC WAY
Practice Address - Street 2:ASPEN COTTAGES
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-5285
Practice Address - Country:US
Practice Address - Phone:706-225-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061214207ND0900X
GA61214207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA874913241AMedicaid
GAP00693238OtherRAILROAD MEDICARE
GAP00693238OtherRAILROAD MEDICARE
GA874913241AMedicaid