DAFTAR JEJARING TRAUMA CENTER DAN FASILITAS KERJASAMA BPJS KETENAGAKERJAAN

Halaman : Tanggal Cetak : Waktu Cetak :

DAFTAR JEJARING TRAUMA CENTER DAN FASILITAS KERJASAMA BPJS KETENAGAKERJAAN

1 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016 KANTOR CABANG

NO

KODE PROVIDER

:

000- KANTOR CABANG AMBON

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000057

DR. CHRISTOFFEL RELMASIRA

JL. ANTHONY REEBOK

351654

DR. CHRISTOFFEL RELMASIRA

PER/011/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

2

1500000000317

RS BERGERAK TIAKUR

TIAKUR MALUKU BARAT DAYA

081343343 290

KAB MALUKU BARAT DAYA

PER/004/032015

RS.TRAUMA CENTRE

01/04/2015

30/03/2016

3

1500000000219

RS BHAYANGKARA POLDA MALUKU

JL SULTAN HASANUDDIN , TANTUI

349450

POLDA MALUKU

PER/001/022015

RS.TRAUMA CENTRE

01/01/2015

31/12/2017

4

1400000000084

RS HATI KUDUS LANGGUR

JL. JEND. SUDIRMAN LANGGUR

21638

IDA RAHAIL, AKP. M.KES

PER/012/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

5

1400000000056

RS HATIVE PASSO

JL. LAKSDA LEO WATTIMENA AMBON

362512

YAYASAN SANTO LUKAS

PER/008/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

6

1400000000042

RST TK II DR J.A. LATTUMETEN

JL DR TAMAELA AMBON

353555

KODAM PATTIMURA

PER/009/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

7

1400000000076

RSU AL FATAH AMBON

JL SULTAN BAABULLAH AMBON

343848

YAYASAN WAKAF AL FATAH

PER/013/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

8

1400000000041

RSUD DR M HAULUSSY

JL KAYADOE AMBON

PEMDA PROV MALUKU

PER/010/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

9

1500000000818

RSUD NAMROLE

JL KAMBOJA

KAB BURU SELATAN

PER/014/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

10

1500000000539

RSUD PIRU

JL ARTERI PIRU

DR MICHEL A SIWABESSY

PER/006/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

11

1500000000620

RSUD PP MAGRETI

JL. THEODORUS RESILOWY, SAUMLAKI

PEMKAB MTB

PER/007/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

12

7-141557413

RUMKITAL DR. F.X. SOEHARDJO

JL LAYAR NO. 1 KOMPLEK ANGKATAN LAUT AMBON

DR . HISNINDARSYAH

001-000112015

RS.TRAUMA CENTRE

24/11/2015

31/10/2017

MA11222I

00000


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NO

KODE PROVIDER

:

001- KANTOR CABANG TERNATE

NAMA PROVIDER

ALAMAT

1

1400000000043

DR. TUTHANURANII NACHRAWY, M. KES

JL. PAHLAWAN REVOLUSI

2

1500000000215

RSU DHARMA IBU

JL PAHLAWAN REVOLUSI NO 5

3

1300000000005

RSUD CHASAN BOISOIRIE TERNATE

JL. TANAH TINGGI

4

1500000000625

RSUD JAILOLO

JL RAYA ACANGO DESA ACANGO KEC JAILOLO

5

05392

RSUD TOBELO

JL. LANDBOUW TOBELO

6

05392

RSUD TOBELO

JL. LANDBOUW TOBELO

7

08186

RUMAH SAKIT DAERAH TIDORE KEPULAUAN

JL. SULTAN MANSYUR INDONESIANA

8

1500000000050

RUMAH SAKIT ISLAM TERNATE

JLN.PEMUDA NO.131 KELURAHAN TOBOLEU TERNATE

9

1500000000050


10

1500000000050

11

12

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR.TUTHANURANI NACHRAWY

PER/003/042015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

3121951

DR.SUTOMO RAHARJO, SP.A

PER/002/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

3121281

PEMDA

PER/001/022015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PEMDA HALBAR

PER/010/012015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

21566

PEMKAB HALUT

PER/07/0032015

FFS

01/04/2015

31/03/2016

21566

PEMKAB HALUT

PER/007/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PEMDA TIDORE KEPULAUAN

01 MEI 2015 S.D 30 APRIL 2016

FFS

01/05/2015

30/04/2016

3121623

YAYASAN ISLAM BINA WARGA

PER/003/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015


3121623


PER/03/122014

FFS

01/01/2015

31/12/2015



3121623


PER/003/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

1500000000035

RUMAH SAKIT MEDIKA HARIFALM

KEL KOTA BARU KOTA TERNATE

DR.AZIS MANAF SP.PD

PER/004/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

1500000000035

RUMAH SAKIT MEDIKA HARIFALM

KEL KOTA BARU KOTA TERNATE

DR.AZIS MANAF SP.PD

PER/001/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000036

RUMAH SAKIT TNI TK IV TERNATE

JL AIS NASUTION NO 2

TNI

PER/009/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

14

1500000000296

RUMAH SAKIT UMUM DAERA WEDA

JL RAYA WEDA

PEMDA HALTENG

PER/006/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

15

1500000000295

RUMAH SAKIT UMUM DAERAH MABA

JL TRANS HALMAHERA KEC KOTA MABA HALMAHERA TIMUR

PEMDA HALMAHERA TIMUR

PER/005/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

KANTOR CABANG

NO

KODE PROVIDER

:

100- KANTOR CABANG SORONG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-136408795

APOTIK KLABOT

JLN SORONG

98451

RINI

123456

RS.TRAUMA CENTRE

22/10/2015

01/12/2016

2

7-136432885

APOTIK MAJU BERSAMA

BUKIT

98451

MR. BUKIT

12546244764564 894

RS.TRAUMA CENTRE

22/10/2015

22/10/2016

3

1500000000503

BALAI LATIHAN KERJA INDUSTRI (BLKI) SORONG

JL BASUKI RAHMAT KM 9.5 KOTA SORONG

YULIANTI MATANDUNG,S.SOS,MM

PER/37/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

4

7-136432856

KLINIK AQILLA

JL MALANU

YOGI

15455421021511 51

RS.TRAUMA CENTRE

22/10/2015

22/10/2016

5

1400000000012

KLINIK MAJU BERSAMA (KLINIK-TC)

JL BASUKI RAHMAT KM 11 (DEPAN BATALION)

DR LIDIA KURNIAWAN

PER/018/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

6

1400000000555

KLINIK MAJU BERSAMA II AIMAS (KTC)

JL WORTEL AIMAS UNIT 2 KAB SORONG

DR. GINDAR SITEPU

PER/044/122015

RS.TRAUMA CENTRE

05/01/2016

30/11/2016

MA11222I

322549

98451

13351490


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

1500000000384

PUSKESAMAS SAYOSA

SAYOSA KAB SORONG

48060504

PER/031/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

8

1500000000383

PUSKESMAS BERAUR (KTC)

BERARUR KAB SORONG

54285228

PER/032/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

9

1500000000434

PUSKESMAS KLABOT (KTC)

KLABOT KABUPATEN SORONG

54173183

PER/030/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

10

1500000000435

PUSKESMAS KLAFDALIM (KTC)

KLASARI KAB SORONG

54173183

PER/023/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

11

1500000000386

PUSKESMAS KLAMONO (KTC)

JL KLAWANA DISTRIK KLAMONO

1060944

PER/028/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

12

1500000000382

PUSKESMAS KLASOUW (KTC)

KLASOUW KAB SORONG

44468629

PER/0034/03201 5

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

13

1500000000376

PUSKESMAS KLAWAK (KTC)

KLAWAK KAB SORONG

62003121

PER/033/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

14

1500000000380

PUSKESMAS KLAYILI (KTC)

KLAYILI KAB SORONG

47330915

PER/036/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

15

1500000000390

PUSKESMAS MAJARAN (KTC)

MAJARAN MARIYAI SP 2

44086493

PER/021/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

16

1500000000388

PUSKESMAS MAKBON (KTC)

MAKBON KAB SORONG

99373405

PER/024/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

17

1500000000391

PUSKESMAS MALAWILI

JL NANGKA KELURAHAN AIMAS KAB SORONG

44181510

PER/019/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

18

1500000000379

PUSKESMAS MARIAT (KTC)

MARIYAI SP 2

39495966

PER/ 020/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

19

1500000000378

PUSKESMAS MARIAT (KTC)

MARIYAI SP 2

39495966

PER/020/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

20

1500000000381

PUSKESMAS MAUDUS (KTC)

MAUDUS KAB SORONG

54691544

PER/035/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

21

1500000000389

PUSKESMAS MAYAMUK (KTC)

JL POROS KELURAHAN MAKBALIM KAB SORONG

44419198

PER/022/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

22

1500000000385

PUSKESMAS MEGA

MEGA KAB SORONG

97935870

PER/029/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

23

1500000000387

PUSKESMAS SAILOLOF

SALAWATI SELATAN KABUPATEN SORONG

19764619

PER/027/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

24

1500000000436

PUSKESMAS SEGET (KTC)

SEGET KAB SORONG

44070654

PER/025/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

25

1500000000377

PUSKESMAS SEGUN (KTC)

SEGUN KAB SORONG

3199503

PER/026/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

26

1500000000592

RS HERLINA (RSTC)

JL SELAT MAKASSAR NO 7

4852341

IR HERLINA SIHOMBING

PER/040/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

27

04658

RS MUTIARA

JL MALEO NO 2 SORONG

095132743 3

DR HJ PAHIMAH/ISKANDAR

PER/001/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

28

1500000000104

RS MUTIARA SORONG (RSTC)

JL MALEO NO 2 KOTA SORONG

327433

DR HJ PAHIMA ISKANDAR

PER/018/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

29

1500000000551

RS PERTAMINA SORONG (RSTC)

JL A YANI NO 13 SORONG PAPUA BARAT

44440220

PER/039/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

30

1400000000022

RSAL DR OETOYO (RS TC)

JLN JEND AHMAD YANI

PER/038/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

31

1400000000408

RSUD KAB RAJA AMPAT (RSTC)

JL DISTRIK WAISAI

44717931

PER/043/112015

RS.TRAUMA CENTRE

01/02/2016

31/10/2016

32

1400000000034

RSUD KAB SORONG (RSTC)

JL KESEHATAN NO 36

321763

PER/41/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

33

1500000000080

RSUD SCHOLOO KEYEN SORSEL (RSTC)

JLN TEMINABUAN AYAMARU KP KEYEN

7705545

PEMDA SORONG SELATAN

PER/016/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2016

34

1500000000101

RSUD SELE BE SOLU KOTA SORONG (RSTC)

JLN BASUKI RAHMAT KM 12 SORONG

8460538

PEMKOT KOTA SORONG

PER/042/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

101- KANTOR CABANG JAYAPURA

NAMA PROVIDER

ALAMAT

1

1500000000501

BLK INDUSTRI PROVINSI PAPUA

JL. PASIFIK INDAH I BASE G JAYAPURA

2

1500000000457

KLINIK PRATAMA BUNDA HATI KUDUS

JL. RAYA MANDALA NO. 26 MERAUKE

3

1500000000455

RS BHAYANGKARA

4

1500000000524

5

1400000000375

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

BLK. INDUSTRI PROV. PAPUA

PER/11/032015

RS.TRAUMA CENTRE

18/03/2015

17/03/2016

KLINIK PRATAMA BUNDA HATI KUDUS

PER/10/0315

RS.TRAUMA CENTRE

18/03/2015

17/03/2016

JL. JERUK NIPIS VURIA

RS BHAYANGKARA

PER/08/022015

RS.TRAUMA CENTRE

26/02/2015

25/02/2017

RS BUNDA PENGHARAPAN MERAUKE

JL. ANGKASA I KELAPA LIMA MERAUKE

RS BUNDA PENGHARAPAN MERAUKE

PER/ 09/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

RS DIAN HARAPAN TRAUMA CENTER

JL. TARUNA BHAKTI WAENA

YAYASAN RS DIAN HARAPAN

PER/15/092015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

44603533

572123


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

RSMI JAYAPURA

PER/18/122015

RS.TRAUMA CENTRE

14/01/2016

31/12/2016

522958

RSAL DR. SOEDIBJO SARDADI

PER/19/122015

RS.TRAUMA CENTRE

14/01/2016

31/12/2016

321512

RSAL KAB. MERAUKE

PER/16/112015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

RSUD ABEPURA

PER/ 12/042015

RS.TRAUMA CENTRE

01/04/2015

01/04/2016

44976339

RSUD KABUPATEN SUPIORI

PER/14/042015

RS.TRAUMA CENTRE

01/04/2015

30/04/2016

JL. BHAYANGKARA KP ASYAMAN DISTRIK ARSO

081148803 0

RSUD KWAINGGA KEEROM

PER/07/022015

RS.TRAUMA CENTRE

25/02/2015

24/02/2016

RSUD MERAUKE TC

JL. SUKARJO WIRYOPRANOTO NO. 1

085244682 879

RSUD MERAUKE

PER/16/112015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

1500000000456

RSUD YOWARI

JL RAYA SENTANI DEPAPRE DOYO BARU KABUPATEN JAYAPURA

085244906 298

RSUD YOWARI

PER/09/022015

RS.TRAUMA CENTRE

25/02/2015

24/05/2016

1500000000828

RUMKITAL DR. R GANDHI A.T BIAK

JL. JENDRAL SUDIRMAN BIAK

44265612

RUMKITAL DR. R GANDHI A.T BIAK

PER/13/042015

RS.TRAUMA CENTRE

01/04/2015

29/04/2016

6

1500000000081

RS MARTHEN INDEY

JL. DIPONEGORO NO. 27 GURABESI

7

1400000000716

RSAL DR. SOEDIBJO SARDADI

JL. AMPHIBI NO. 1 HAMADI

8

1400000000514

RSAL MERAUKE TC

JL. TRIKORA MERAUKE

9

1500000000525

RSUD ABEPURA

JL. KESEHATAN NO. 1 ABEPURA

10

1500000000829

RSUD KABUPATEN SUPIORI

JL. SORENDIWERI KORIDO SUPIORI

11

1500000000454

RSUD KWAINGGA KEEROM

12

1400000000515

13

14

KANTOR CABANG

MA11222I

:

102- KANTOR CABANG MIMIKA


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

TIPE IKS

AWAL IKS

AKHIR IKS 31/12/2015

RSUD NABIRE

PER/03/032015

RS.TRAUMA CENTRE

01/03/2015

28/03/2016

JLN. CHARITAS NO. 1

YAYASAN CARITAS

PER/02/022015

RS.TRAUMA CENTRE

01/02/2015

29/02/2016

JLN YOS SUDARSO NAWARIPI

RSUD MIMIKA

PER/07/032015

RS.TRAUMA CENTRE

01/04/2015

30/04/2016

JLN AGATS KABUPATEN ASMAT

2

1500000000258

RSUD KABUPATEN NABIRE

LN. RE. MARTHADINATA NABIRE PAPUA

3

1500000000174

RUMAH SAKIT MITRA MASYARAKAT

4

1500000000345

RUMAH SAKIT UMUM DAERAH (RSUD) MIMIKA

KODE PROVIDER

NO IKS

01/01/2015

RSUD KABUPATEN ASMAT

NO

PIMPINAN

RS.TRAUMA CENTRE

1400000000573

:

IKS TELEPON

PER/013/122014

1

KANTOR CABANG

KODE POS

A00- KANTOR CABANG LHOKSEUMAWE

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000446

KLINIK HUSADA

JL TGK CHIK DITUNONG GAMPONG KUTA LHOKSUKON KEC. LHOKSUKON KAB. ACEH UTARA

31120

JAMALUDDIN

PER/10/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

2

1500000000228

KLINIK LHOKSEUMAWE HUSADA

JLN. MERDEKA BARAT NO.12 F GAMPONG KUTA BLANG KEC. BANDA SAKTI

081396697 999

DR. HJ. KIKIE INDRIATY

PER/04/022015

RS.TRAUMA CENTRE

13/02/2015

12/02/2016

3

1500000000125

KLINIK MITA SEHAT

JL. MEDAN-BANDA ACEH GAMPONG TAMBON BAROH KEC. DEWANTARA

085277907 770

H. IRSYAD H. ABDULLAH

PER/01/012015

RS.TRAUMA CENTRE

02/01/2015

01/01/2016

4

1500000000229

KLINIK VINCA ROSEA LHOKSEUMAWE

JL. DARUSSALAM NO. 36 GAMPONG JAWA BARU

AZHARI

PER/19/122014

RS.TRAUMA CENTRE

02/01/2015

01/01/2016

5

1500000000225

KLINIK VINCA ROSEA TAKENGON

JLN. ABDUL WAHAB KP. SIMPANG EMPAT KECAMATAN BEBESAN

AZHARI

PER/20/122014

RS.TRAUMA CENTRE

02/01/2015

01/01/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

6

1500000000630

PUSKESMAS PAYA BAKONG

JL TGK SYIK PAYA BAKONG CEUMPEUDAK KAB ACEH UTARA

7

7-1092257715

RSUD DATU BERU KABUPATEN ACEH TENGAH

JL. RUMAH SAKIT UMUM NO. 153 TAKENGON

8

1500000000127

RUMAH SAKIT AVICENNA BIREUEN

9

1500000000406

RUMAH SAKIT KASIH IBU

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. WAHYUDI HIDAYAT

441/211/PKM/20 15

RS.TRAUMA CENTRE

21/04/2015

20/04/2016

064321396

DR. HARDI YANIS, SPPD

PER/25/102015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

JL KUALA RAJA NO.1 GAMPONG LHOK AWE TEUNGOH KECAMATAN KOTA JUANG

22887

DR.FAISAL,SP.OG

PER/02/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

JL MERDEKA NO 17 GP KUTA BLANG KEC BANDA SAKTI KOTA LHOKSEUMAWE

48713

HJ HERAWATI

PER/05/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

24511

A01- KANTOR CABANG BANDA ACEH

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000167

BLUD RS IBU DAN ANAK ACEH

JL. PROF. A. MAJID IBRAHIM I NO. 3 KEL. PUNGE JURONG KEC MEURAXA

637433

PEMERINTAH ACEH

PER/08/022015

RS.TRAUMA CENTRE

04/02/2015

03/02/2016

2

1400000000569

CEMPAKA LIMA

JLN. TGK. H. M. DAUD BEUREUEH NO.78 A BEURAWE KEC.KUTA ALAM KOTA BANDA ACEH

33345

HJ. KARTINI.N.I

PER/38/122015

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

3

1500000000056

KLINIK AA MEDICAL

JL SIGLI -KB. TANJONG NO.1 GP.PANTE KEC. SIMPANG TIGA KAB.PIDIE

HJ. AGUSMIATI, S.SI.T

PER/03/012015

RS.TRAUMA CENTRE

07/01/2015

06/01/2016

4

1400000000566

KLINIK ATHARI

JL. RUKOH UTAMA NO.21 GP. RUKOH KEC. SYIAH KUALA -KOTA BANDA ACEH

DR. TEUKU MUHAMMAD YUS

PER/37/122015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

5

1500000000122

KLINIK CAHAYA BUNDA

JL. KEBUN RAJA GP. IE MASEN KEC. ULEE KARENG BATA KOTA BANDA ACEH

DR.BUDI PERMANA

PER/06/012015

RS.TRAUMA CENTRE

28/01/2015

27/01/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6

1500000000122

KLINIK CAHAYA BUNDA

JL. KEBUN RAJA GP. IE MASEN KEC. ULEE KARENG BATA KOTA BANDA ACEH

DR.BUDI PERMANA

PER/08/022016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

7

1500000000055

KLINIK KELUARGA ASMAUL HUSNA

GAMPONG ULEE GLE KEC BANDAR DUA

SAIFUL BAHRI IDRIS

PER/04/012016

RS.TRAUMA CENTRE

27/01/2016

31/12/2016

8

1500000000153

KLINIK KIMIA FARMA

JL. PERDAGANGAN NO. 1 KOTA SIGLI KEC. KOTA SIGLI KAB. PIDIE

M. BAGUS ANDREAS TAUFANI, S.FARM, APT

PER/07/012015

RS.TRAUMA CENTRE

03/02/2015

02/02/2016

9

1500000000019

KLINIK LATIFAH

JL. SOEKARNO -HATTA N0.04 DSN. MELATI GP. GAROT KEC. DARUL IMARAH KAB. ACEH BESAR

SISKA ARSYAD, S.KED

PER/01/012015

RS.TRAUMA CENTRE

06/01/2015

05/01/2016

10

1500000001919

KLINIK MITRA MEDISTRA

JL. RESIDEN DANUBROTO GP. LAMLAGANG KEC. BANDA RAYA

AZIZURRAHMAN, SKM,MM

PER/24/072015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

11

1500000000105

KLINIK NABILA

JL. STA. MAHMUDSYAH N0.9 GP.BARU KEC. BAITURRAHMAN

33555

DR. RACHMI KURNIAWATI

PER/04/012015

RS.TRAUMA CENTRE

16/01/2015

15/01/2016

12

7-1676350253

KLINIK RANUP PEUNAWA MEDIKA

JL SOEKARNO HATTA GP LAMPEUNEURUT UJONG BLANG KEC DARUL IMARAH KAB. ACEH BESAR

72303666

CAPT. FADLI, SE, M.MAR

PER/05/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

13

1500000000242

KLINIK UMMI AISYAH

JL. PERDAGANGAN GAMPONG KUTA BARAT KOTA SABANG

MINALTIWATI, AMD.KEB

PER/13/022105

RS.TRAUMA CENTRE

27/02/2015

26/02/2016

14

1500000000569

PIUSKESMAS MONTASIK

JLN. AYAHANDA TGK SYEKH IBRAHIM MONTASIK PASAR COT GOH, KEC MONTASIK

DINKES ACEH BESAR

PER / 19.16 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

15

1500000000555

PUSKEMAS LHOKNGA

DESA MONIKEN, PASAR LHOKNGA

DINAS KESEHATAN ACEH BESAR

PER / 19.02 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

16

1500000000561

PUSKEMAS SEULIMUM

JLN B.ACEH - MEDAN KM 42 DESA SEUNEBOK, SEULIMUM TLP. 93026

DINKES ACEH BESAR

PER / 19.07 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

17

1500000000567

PUSKESMAS BAITUSSALAM

JL. LAKSAMANA MALAHAYATI KM. 10,5 KEC. BAITUSSALAM

DINKES ACEH BESAR

PER / 19.14 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

21536

23111

23352


SM0480



11 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

18

1500000000581

PUSKESMAS BLANG BINTANG

DESA KAMPONG BLANG, KEC. BLANG BINTANG. JLN. SULTAN ISKANDAR MUDA

19

1500000000576

PUSKESMAS DARUL IMARAH

JLN. ELAK- BILUY (0651 ) 48375

20

1500000000577

PUSKESMAS DARUL KAMAL

21

1500000000566

22

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DINKES ACEH BESAR

PER / 19.28 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

DINKES ACEH BESAR

PER / 19.23 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

JLN. TGK FAKINAH KM.9 PEUKAN BILUY KODE POS 23352

DINKES ACEH BESAR

PER / 19.23 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PUSKESMAS DARUSSALAM

JL. LAMBARO ANGAN, KEC. DARUSSALAM, KODE POS 23373

DINKES ACEH BESAR

PER / 19.13 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

1500000000560

PUSKESMAS IE ALANG

GAMPONG IE ALANG MESJID

DINKES ACEH BESAR

PER / 19.07 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

23

1500000000557

PUSKESMAS INDRAPURI

JLN. B. ACEH - MEDAN KM 25 ( 0651 ) 24657 KODE POS 23363

DINKES ACEH BESAR

PER / 19.04 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

24

1500000000571

PUSKESMAS INGIN JAYA

JLN. B.ACEH MEDAN KM 8,5 LAMBARO

DINKES ACEH BESAR

PER / 19.18 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

25

1500000000563

PUSKESMAS KOTA JANTHO

JLN. TEUREUBEH KOTA JANTHO TLP. (0651 ) 92601 KODE POS 23918

DINKES ACEH BESAR

PER / 19.10 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

26

1500000000572

PUSKESMAS KRUENG BARONA JAYA

JL. T. ISKANDAR, KM. 5 DESA COT IRIE, KEC. KRUENG BARONA JAYA

DINKES ACEH BESAR

PER / 19.19 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

27

1500000000568

PUSKESMAS KUTA BARO

JL. BLANG BINTANG LAMA KM. 10,5 , PEUKAN ATEUK, KEC KUTA BARO KODE POS 23372 TLP. ( 0651 ) 581159

DINKES ACEH BESAR

PER / 19.15 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

28

1500000000559

PUSKESMAS KUTA COTGLIE

JL. BANDA ACEH-MEDAN KM. 36, LAMPAKUK

DINKES ACEH BESAR

PER / 19.06 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

29

1500000000574

PUSKESMAS KUTA MALAKA

JL. BANDA ACEH-MEDAN KM. 19,5 SAMAHANI

DINKES ACEH BESAR

PER / 19.21 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

48375

2790


SM0480



12 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

30

1500000000579

PUSKESMAS LAMPISANG

JL. B. ACEH-MEULABOH, DESA LAMPISANG KEC. PEUKAN BADA

DINKES ACEH BESAR

PER / 19.26 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

31

1500000000558

PUSKESMAS LAMPUPOK

JLN.BANDA ACEH MEDAN KM 23. LAMPUPOK RAYA, INDRAPURI

DINKES ACEH BESAR

PER / 19.04 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

32

1500000000562

PUSKESMAS LAMTEUBA

DESA LAMTEUBA DROE, KEC. SEULIMUM.

DINKES ACEH BESAR

PER / 19.09 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

33

1500000000564

PUSKESMAS LEMBAH SEULAWAH

GAMPONG ACEH SUKADAMAI, SAREE, KEC. LEMBAH SEULAWAH KODE POS 23952

DINKES ACEH BESAR

PER / 19.11 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

34

1500000000556

PUSKESMAS LEUPUNG

JLN. B.ACEH - MEULABOH KM. 30 KEDE POS 23353

DINKES ACEH BESAR

PER / 19.03 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

35

1500000000554

PUSKESMAS LHOONG

JLN. B. ACEH - MEULABOH KM. 54 KODE POS 23354

DINAS KESEHATAN ACEH BESAR

PER / 19.01 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

36

1500000000565

PUSKESMAS MESJID RAYA

JL. LAKSAMANA MALAHAYATI DESA MEUNASAH KEUDE, KRUENG RAYA

DINKES ACEH BESAR

PER / 19.12 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

37

1500000000578

PUSKESMAS PEUKAN BADA

JLN. MESJID TGK CHIK MAHARAJA GURAH NO. 03 KODE POS 23351

DINKES ACEH BESAR

PER / 19.25 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

38

1500000000570

PUSKESMAS PIYEUNG

JLN AYAHANDA

DINKES ACEH BESAR

PER / 19.17 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

39

1500000000580

PUSKESMAS PULO ACEH

DESA LAMPUYANG, PULAU BREUH, KEC. PULO ACEH.

DINKES ACEH BESAR

PER / 19.27 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

40

1500000000575

PUSKESMAS SIMPANG TIGA

JL. T. FAKINAH, DESA KRUENG MAK, SIMPANG TIGA

DINKES ACEH BESAR

PER / 19.22 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

41

1500000000573

PUSKESMAS SUKAMAKMUR

JLN. B. ACEH - MEDAN KM 16,5 SIBREH

DINKES ACEH BESAR

PER / 19.20 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

7400250


SM0480



13 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

42

1400000000191

RS CITRA HUSADA SIGLI

JL. PROF MAJID IBRAHIM LAMPEUDEU BAROH KOTA SIGLI KABUPATEN PIDIE

96707970

DR JULIANA SP AK

PER/28/092015

RS.TRAUMA CENTRE

12/01/2016

01/09/2016

43

1400000000073

RS HARAPAN BUNDA

JL T UMAR NO 181-185 GP SEUTUI

48114

DR. ZAINAL BAKRI SPOG

PER/15/032015

RS.TRAUMA CENTRE

25/02/2015

24/02/2016

44

1500000001060

RSUD KAB. ACEH BESAR

JL. BANDA ACEH-MEDAN KM. 25 GP.SINYEU KEC. INDRAPURI, KABUPATEN ACEH BESAR

DINKES ACEH BESAR

PER / 20/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

45

1500000001923

RSUD MEURAXA

JL. SOEKARNO HATTA KM.2 MIBO KEC. BANDA RAYA

43097

PEMERINTAH KOTA BANDA ACEH

PER/ 25/ 082015

RS.TRAUMA CENTRE

18/08/2015

17/08/2017

46

1500000000093

RUMAH SAKIT IBNU SINA

JL B. ACEH-MEDAN KM 25,5 DESA SINYEU KEC INDRAPURI

085238105 999

DIANA PURWANI

PER/36//12/2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

47

1500000000124

RUMAH SAKIT MALAHAYATI

JL CUT NYAK DHIEN NO 498 LAMTEUMEN TIMUR

32874

YAYASAN RS MALAHAYATI

PER/05/012015

RS.TRAUMA CENTRE

16/01/2015

15/01/2016

48

1400000000194

RUMAH SAKIT TGK FAKINAH

JL. JEND SUDIRMAN NO. 17, KOTA BANDA ACEH

44114

YAYASAN TGK FAKINAH

PER/34/122015

RS.TRAUMA CENTRE

12/01/2016

01/01/2017

49

1400000000194

RUMAH SAKIT TGK FAKINAH

JL. JEND SUDIRMAN NO. 17, KOTA BANDA ACEH

44114

YAYASAN TGK FAKINAH

PER/23/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

50

1400000000570

RUMAH SAKIT U'BUDIYAH

7555750

PT. CAISARIO ROYAL PRATAMA

PER/35/122015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

51

1500000000302

RUMAH SAKIT UMUM BULAN SABIT MERAH

JL. SULTAN MALIKUL SALEH NO.17 GP. LAMLAGANG , KEC. BANDA RAYA

HERI RISWANDI

PER/16/ 032015

RS.TRAUMA CENTRE

02/03/2015

01/03/2016

52

1500000000166

RUMKIIT BHAYANGKARA

JL. CUT NYAK DHIEN NO. 1 KEL. LAMTEUMEN

KEPOLISIAN REPUBLIK INDONESIA

PER/09/022015

RS.TRAUMA CENTRE

05/02/2015

04/02/2016

KANTOR CABANG

MA11222I

:

23111

41470

A02- KANTOR CABANG LANGSA


SM0480



14 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000546

DR. SYARIFAH RINA MARLINA

JL. H AGUSSALIM NO. 20 KAMPUNG BLANG LANGSA KOTA

20354

DR. SYARIFAH RINA MARLINA

PER/02/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

2

1400000000552

KLINIK BINA HUSADA

JL. T. CHIK DITIRO NO. 3 GAMPONG PAYA BUJOK TUNONG LANGSA BARO

085336187 3663

DR H SYAFRIRUDDIN, MM

PER/17/012016

RS.TRAUMA CENTRE

27/01/2016

31/12/2016

3

1500000000039

PUSKESMAS BANDA MULIA

KECAMATAN BANDA MULIA

085275453 457

COCO ARMANSYAH, SKM

PER/12/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

4

1500000000037

PUSKESMAS BANDAR PUSAKA

KECAMATAN BANDAR PUSAKA

085363910 858

SYAMSUDDIN, SKM

PER/14/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

5

1500000000037

PUSKESMAS BANDAR PUSAKA

KECAMATAN BANDAR PUSAKA

085363910 858

SYAMSUDDIN, SKM

PER/04/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2017

6

1500000000023

PUSKESMAS BENDAHARA

KECAMATAN BENDAHARA

085277213 585

RADHIYAH, SKM

PER/02/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

7

1500000000024

PUSKESMAS KARANG BARU

KECAMATAN KARANG BARU

085276981 936

SARI INDAH FITHRIANY, SA.SKM

PER/05/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

8

1500000000042

PUSKESMAS KEJURUAN MUDA

KECAMATAN KEJURUAN MUDA

085275231 971

HJ. MULYANI, S.KEP

PER/09/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

9

1500000000043

PUSKESMAS KOTA KUALA SIMPANG

KECAMATAN KUALA SIMPANG

085272110 394

IDA IRAWATI

PER/08/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

10

1500000000398

PUSKESMAS LANGSA BARAT

JL. PROF A.MAJID IBRAHIM DESA BIREM PUNTONG KEC LANGSA BARAT

23093

AYU ARTLINTA, SKM, M.KES

PER/16/022015

RS.TRAUMA CENTRE

02/02/2015

31/12/2015

11

1500000000396

PUSKESMAS LANGSA BARO

JL. LILAWANGSA NO. 01 PAYA BUJOK TUNONG KEC LANGSA BARO

SAFRITA, SKM

PER/17/022015

RS.TRAUMA CENTRE

02/02/2015

31/12/2015

12

1500000000522

PUSKESMAS LANGSA KOTA

JLN H. AGUS SALIM NO. 10 SUNGAI PAUH KEC LANGSA BARAT KOTA LANGSA

DR. T CHIK M. IQBAL F

PER/15/022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

MA11222I

69222267


SM0480



15 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000395

PUSKESMAS LANGSA LAMA

JL PENDIDIKAN DS MEURANDEH DAYA KEC LANGSA LAMA

NS. EDI SYAHPUTRA, S.KEP

PER/19/022015

RS.TRAUMA CENTRE

02/02/2015

31/12/2015

14

1500000000397

PUSKESMAS LANGSA TIMUR

JL. MEDAN-BANDA ACEH KM. 7 GP ALUE PINEUNG KEC LANGSA TIMUR

DR. MAHLIDAYANTI

PER/18/022015

RS.TRAUMA CENTRE

02/02/2015

31/12/2015

15

1500000000022

PUSKESMAS MANYAK PAYED

KECAMATAN MANYAK PAYED

085358091 334

DR. FITRIYANTI

PER/01/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

16

1500000000045

PUSKESMAS RANTAU

KECAMATAN RANTAU

081260441 263

DR TSUAIBAHTUL ASLAMIYAH NASUTION

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

17

1500000000044

PUSKESMAS SAPTA JAYA

KECAMATAN SAPTA JAYA

085260746 332

DR. DANANG ARMAN MUNANTO

PER/07/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

18

1500000000040

PUSKESMAS SEKERAK

KECAMATAN SEKERAK

082168103 036

DR. ABDUL GAFUR

PER/11/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

19

1500000000040

PUSKESMAS SEKERAK

KECAMATAN SEKERAK

082168103 036

DR. ABDUL GAFUR

PER/03/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2017

20

1500000000026

PUSKESMAS SERUWAY

KECAMATAN SERUWAY

085270118 101

JAMILAH, SKM

PER/04/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

21

1500000000038

PUSKESMAS SIMPANG KIRI

KECAMATAN SIMPANG KIRI

081265193 134

DR. SANDY PRAMAYUDHA

PER/13/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1500000000025

PUSKESMAS SUNGAI IYU

DS SUNGAI IYU KECAMATAN BENDAHARA

081263173 69

IRWANUDDIN, SKM

PER/03/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

23

1500000000041

PUSKESMAS TAMIANG HULU

KECAMATAN TAMIANG HULU

081161333 19

DRG. MIKYAL AYYA RIEFKA

PER/10/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

1400000000340

RSU CUT MEUTIA

JL GARUDA NOMOR 1 KEBUN BARU KECAMATAN LANGSA BARO

23071

IR EDDY PURNOMO

PER/01/012016

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

MA11222I


SM0480



16 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1400000000340

RSU CUT MEUTIA


23071

IR EDDY PURNOMO

PER/06/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

1400000000340

RSU CUT MEUTIA


23071

IR EDDY PURNOMO

PER/25/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

27

1400000000675

RSU CUT NYAK DHIEN

JL. T.M. BACHRUM NO 1 KOTA LANGSA

22228

DR YUSUF, MM

PER/10/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

28

1400000000675

RSU CUT NYAK DHIEN

JL. T.M. BACHRUM NO 1 KOTA LANGSA

22228

DR YUSUF, MM

PER/01/012016

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

29

1500000000034

RSUD KOTA LANGSA

JALAN JEND. AHMAD YANI NO 1 KOTA LANGSA

22051

DR. HERMAN I

PER/11/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

30

1500000000034

RSUD KOTA LANGSA

JALAN JEND. AHMAD YANI NO 1 KOTA LANGSA

22051

DR. HERMAN I

PER/18/012016

RS.TRAUMA CENTRE

27/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

A03- KANTOR CABANG MEULABOH

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000612

KLINIK ANANDA FAMILY

JL. CUT MEUTIA NO.34 MEULABOH

23611

DR. MARHABAN

PER/08/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1400000000610

KLINIK CEMPAKA LIMA MEULABOH

JL. SWADAYA NO.39F-H MEULABOH

23611

AMIR HIDAYAT, ST

PER/07/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1400000000613

KLINIK GRAHA UMMI

JL. IMAM BONJOL NO. 27-28 SEUNEUBOK MEULABOH

DERI DARMAWAN, S.PI

PER/12/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. MUTIA DARMAWAN

PER/13/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23662

AJA PUTRI

PER/03/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

DESA ALUE RAMBOT, KEC. DARUL MAKMUR

23662

DR, CHAIDIR

PER/20/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PUSKESMAS BEUTONG

LHOK SEUMOT, KEC.BEUTONG

23672

HJ. NURLIMPAH

PER/10/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1500000000004

PUSKESMAS BEUTONG ATEUH

DESA KRUENG CUT

23672

MUHAMMAD DAUD, SKM

PER/39/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

9

1500000000010

PUSKESMAS COT KUTA

JL. NASIONAL MBO-JEURAM, KEC. SEUNAGAN

23671

NEVI HASNITA, SKM

PER/09/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1400000000631

PUSKESMAS COT SEUMEREUNG ACEH BARAT

DS. COT SEUMEUREUNG, KEC. SAMATIGA

23652

DR. SUSANTI

PER/21/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

11

1400000000630

PUSKESMAS DRIEN RAMPAK ACEH BARAT

JL. MEULABOH - BANDA ACEH, KEC. ARONGAN LAMBALEK

23652

MUHAMMAD NASIR,SKM

PER/31/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

12

1500000000008

PUSKESMAS JEURAM

JL. KESEHATAN NO.2, KEC. SEUNAGAN

23671

NURZAINI

PER/33/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

13

1400000000646

PUSKESMAS JOHAN PAHLAWAN ACEH BARAT

JL. TGK DIRUNDENG MEULABOH, KEC. JOHAN PAHLAWAN

23615

DR. ANDI LIDIAWATI

PER/22/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

14

1400000000615

PUSKESMAS KAJEUNG ACEH BARAT

DS. KAJEUNG, KEC. SUNGAI MAS

23681

ZULHAMDI ,AMK

PER/27/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

15

1500000000005

PUSKESMAS KUALA TADU

DS. KUALA TADU, KEC. TADU RAYA

23661

DARMANSYAH,S.ST

PER/18/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1400000000611

KLINIK JEUMPA MEDICA

JL. GAJA MADA NO.40 MEULABOH

5

1500000000012

PUSKESMAS ALUE BILIE

JL. ERWIN IBRAHIM, KEC. DARUL MAKMUR

6

1500000000002

PUSKESMAS ALUE RAMBOT

7

1500000000013

8

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1400000000629

PUSKESMAS LAYUNG ACEH BARAT

JL. SUAK TIMAH KUALA BHEE KM 12, KEC. BUBON

23652

SALMAN RUSLI, SKM.,M.EPID

PER/30/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

17

1500000000003

PUSKESMAS LUENG KEUBEU JAGAT

DESA LUENG KEUBEU JAGAT

23662

DEWI SARTIKA, AMK

PER/19/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

18

1400000000621

PUSKESMAS MEUREUBO ACEH BARAT

JL. NASIONAL DS. UJUNG TANJUNG, KEC. MEUREUBO

23615

DR. DEPI ARISANDI AJI

PER/23/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

19

1400000000616

PUSKESMAS MEUTULANG ACEH BARAT

JL. MEULABOH MEUTULANG, KEC. PANTON REU

23681

HASANUDDIN D, SE

PER/26/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

20

1500000000006

PUSKESMAS PADANG PANJANG

PADANG PANYANG, KEC. KUALA PESISIR

23661

INTAN MALA, A.MD.KEB

PER/05/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1500000000011

PUSKESMAS PADANG RUBEK

DS. PADANG RUBEK, KEC. KUALA PESISIR

23661

DR. ZURRIATY SAVITRI

PER/04/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

1400000000617

PUSKESMAS PANTE CEUREUMEN

DS. PANTE CEUREUMEN, KEC. PANTE CEUREUMEN

23681

MUHAMMAD AMIN, SE

PER/25/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

23

1400000000618

PUSKESMAS PEUREUMUE ACEH BARAT

JL. MEULABOH TUTUL, KEC. KAWAY XVI

23681

NILA TRISNA HD, AMK

PER/24/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

24

1400000000623

PUSKESMAS PIR BATEE PUTEH ACEH BARAT

DS. PASI MALL, KEC. WOYLA BARAT

23682

CUT ELI YUSRA

PER/32/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

25

1400000000623

PUSKESMAS PIR BATEE PUTEH ACEH BARAT

DS. PASI MALL, KEC. WOYLA BARAT

23682

CUT ELI YUSRA

PER/28/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000000007

PUSKESMAS SIMPANG JAYA

JL. MBO-TPK TUAN, KEC. TADU RAYA

23661

SITI ROMLAH

PER/34/12215

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

27

1400000000648

PUSKESMAS SUAK RIBEE ACEH BARAT

JL. KUTA PAYA SUAK RIBEE MEULABOH, KEC. JOHAN PAHLAWAN

23615

DR. SITI HAWANI

PER/28/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

28

1500000000001

PUSKESMAS SUKA MULIA

JL. SEUNEUAM, KEC. DARUL MAKMUR

23662

JAMAL SUNGAEDI, SKM

PER/37/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

29

1500000000016

PUSKESMAS TANGKEH

DS. TANGKEH, KEC. WOYLA TIMUR

23682

ADNEN AR, AMK

PER/35/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

30

1500000000009

PUSKESMAS UJONG FATIHAH

DS. BLANG MUKO, KEC. KUALA

23661

CUT NIH

PER/38/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

31

1500000000014

PUSKESMAS UTEUN PULO

DS. BLANG PANYANG, KEC. SEUNANGAN TIMUR

23671

HJ. YUSNIDAR

PER/36/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

32

1400000000624

PUSKESMAS WOYLA ACEH BARAT

DS. KUALA BHEE, KEC. WOYLA

23654

YESWARDI, SKM

PER/29/122015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

33

08465

RSU MONTELLA

JL. SENTOSA KEL. DRIEN RAMPAK KEC. JOHAN PAHLAWAN MEULABOH

SYARIFAH MERY MIRNA S.SI. APT

PER/02/092015

RS.TRAUMA CENTRE

31/12/2015

31/08/2016

34

1500000000246

RSU SWASTA HARAPAN SEHAT MEULABOH

JL. SISINGAMANGARAJA DESA GAMPA KEC. JOHAN PAHLAWAN KAB. ACEH BARAT

DR. MURDIATI M. KES

PER/06/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

35

1400000000379

RSU SWASTA MONTELLA MEULABOH

JL. BERINGIN JATA DUSUN COT GAMPONG SEUNEUBOK KEC. JOHAN PAHLAWAN

SYARIFAH MERI MERDIANA, S.SI.,APT

PER/02/092015

RS.TRAUMA CENTRE

31/12/2015

31/08/2016

36

1500000000245

RSUD ACEH SINGKIL

JL. RIMO-SINGKIL KM.8 ACEH SINGKIL

PEMDA ACEH SINGKIL

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

37

1500000000245

RSUD ACEH SINGKIL

JL. RIMO-SINGKIL KM.8 ACEH SINGKIL

PEMDA ACEH SINGKIL

PER/17/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

1400000000273

RSUD CUT NYAK DHIEN MEULABOH

JL. GAJAH MADA MEULABOH

21137

PEMKAB ACEH BARAT

PER/01/062015

RS.TRAUMA CENTRE

29/12/2015

30/06/2016

39

1500000000136

RSUD DR H YULIDDIN AWAY

JL T. BEN MAHMUD NO 86 A, TAPAKTUAN ACEH SELATAN, ACEH

323615

PEMKAB ACEH SELATAN

PER/43/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

77999012

23615

23616


SM0480



20 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

40

1500000000136

RSUD DR H YULIDDIN AWAY

JL T. BEN MAHMUD NO 86 A, TAPAKTUAN ACEH SELATAN, ACEH

323615

PEMKAB ACEH SELATAN

PER/14/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

41

1500000000123

RSUD KOTA SUBULUSSALAM

JALAN SUBUSSALAM RUNDING KM.5 DUSUN RAHMAH KEC. SIMPANG KIRI KOTA SUBUSSALAM

62731700

PEMKOT SUBULUSSALAM

PER/44/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

42

1500000000123

RSUD KOTA SUBULUSSALAM

JALAN SUBUSSALAM RUNDING KM.5 DUSUN RAHMAH KEC. SIMPANG KIRI KOTA SUBUSSALAM

62731700

PEMKOT SUBULUSSALAM

PER/15/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

43

1400000000602

RSUD TEUKU UMAR

JLN. GUNONG ALI LR. PMI NO.1 CALANG KEC. KRUENG SABEE

2210322

DR. SUZANNA OCTIVA, SP.KJ

PER/06/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

44

1500000000015

RSUD TEUNGKU PEUKAN

BLANG PIDIE,ACEH BARAT DAYA

92522

DARUSMAN, M.KES (MMR)

PER/11/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

45

1400000000614

RUMAH SAKIT TINGKAT IV IM 07.02 MEULABOH

JL. MERAH PUTIH GAMPONG SUAK INDRAPURI KEC. JOHAN PAHLAWAN

KAPTEM CKM DR. TEGUH ISMANTO,SP.AN

PER/16/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

23654

B00- KANTOR CABANG MEDAN KOTA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000127

BP HARAPAN BUNDA

JL. BRIGJEND ZEIN HAMID NO 39 TITI KUNING

7852636

NETTY BARITA, SE

PER/21/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

2

1400000000127

BP HARAPAN BUNDA


7852636

NETTY BARITA, SE

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1400000000127

BP HARAPAN BUNDA


7852636

NETTY BARITA, SE

PER/13/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000000065

BP HARAPAN BUNDA 1

JL BALAI DESA NO 7 MEDAN POLONIA

6504129

NETTY BARITA,SE

PER/07/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

5

1500000000065

BP HARAPAN BUNDA 1

JL BALAI DESA NO 7 MEDAN POLONIA

6504129

NETTY BARITA,SE

PER/22/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

6

1500000000066

BP HARAPAN BUNDA 3

JL BRIGJEN KATAMSO NO 440 B

NETTY BARITA SE

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

7

1500000000066

BP HARAPAN BUNDA 3

JL BRIGJEN KATAMSO NO 440 B

NETTY BARITA SE

PER/11/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

8

1500000000201

BP KURNIA

JL BINJAI KM 8.8 NO 11 KP LALANG MEDAN

850915

TAN ERFI

PER/21/022015

RS.TRAUMA CENTRE

18/02/2015

17/02/2016

9

1500000000199

KLINIK ADISMA HUSADA DARUSSALAM

JL DARUSSALAM NO 5A

4153169

DR H SAYID BUDHI

PER/13/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

10

1500000000198

KLINIK ADISMA HUSADA TEMBUNG

JL BESAR MEDAN BATANG KUIS DSN XI TEMBUNG

7383103

DR SAYID BUDHI

PER/14/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

11

1500000000196

KLINIK AKSARA

JL AKSARA NO 120 MEDAN

97374384

TEGUH SUHARTO, SE

PER/16/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

12

1500000000206

KLINIK AVIATI 1

JL JAMIN GINTING NO 15 P BULAN MEDAN BARU

6103683

DRG AMETA PRIMASARI TARIGAN

PER/09/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

13

1500000000207

KLINIK AVIATI 3

JL JAMIN GINTING KM 8.5 KOMP DELTA NO 5 MEDAN TUNTUNGAN

3436450

DRG AMETA PRIMASARI TARIGAN

PER/10/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

14

1500000000203

KLINIK AZIZZI GATOT SUBROTO

JL JEND GATOT SUBROTO NO 333 MEDAN

4155528

DRS H RAZALI ROHIMUN

PER/11/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

15

1500000000202

KLINIK AZIZZI SUMARSONO

JL KAPT SUMARSONO NO 74 MEDAN

80030330

DR RIYADH IKHSAN

PER/12/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1500000000194

KLINIK BERSAMA

JL JAMIN GINTING NO 502 P BULAN MEDAN

68272131

SAMPE REZEKI, SE

PER/15/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

17

1400000000126

KLINIK CITRA MEDIKA

JALAN SISINGAMANGARAJA NO 7 KM 4,5

7863134

DR YUDHA PRAYOGI

PER/02/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

18

1400000000126

KLINIK CITRA MEDIKA

JALAN SISINGAMANGARAJA NO 7 KM 4,5

7863134

DR YUDHA PRAYOGI

PER/20/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

19

1500000000195

KLINIK GRIYA MEDICAL CENTER

JL KAPTEN MUSLIM NO 43B

97374384

TEGUH SUHARTO,SE

PER/17/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

20

1500000000189

KLINIK MADANI

JL. BESAR NAMORAMBE TITI KUNING

7032626

DR. H DEPI MASRI

PER/12/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

21

1500000000189

KLINIK MADANI

JL. BESAR NAMORAMBE TITI KUNING

7032626

DR. H DEPI MASRI

PER/08/012015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

22

1500000001611

KLINIK MILLENIUM

JL KAPTEN MUSLIM NO 58C

63792195

SRI REZEKI SE

PER/27/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

23

1500000000197

KLINIK SENYUM JAYA ABADI

JL SETIABUDI NO 117 LINK V TG SARI

8219006

DRG ERITA FLORA MANURUNG

PER/23/022015

RS.TRAUMA CENTRE

18/02/2015

17/02/2016

24

1500000000270

PUSKESMAS AMPLAS

JL SM RAJA

7862798

PER/25/022015.0 1

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

25

1500000000271

PUSKESMAS BESTARI

JL ROTAN KOMP PETISAH

4150066

PER/25/022015.0 2

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

26

1500000000280

PUSKESMAS DARUSSALAM

JL DARUSSALAM

PER/25/022015.0 3

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

27

1500000000279

PUSKESMAS DESA LALANG

JL BINJAI KM 7.5

PER/02/2015.04

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

MA11222I

5237868


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/25/022015.0 5

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

PER/25/022015.0 8

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

PER/25/022015.0 6

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

JL AMALIUN

PER/25/022015

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

PUSKESMAS MEDAN JOHOR

JL KARYA DHARMA

PER/25/022015.0 9

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

1500000000273

PUSKESMAS MEDAN POLONIA

JL POLONIA

PER/25/022015.1 0

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

34

1500000000272

PUSKESMAS MEDAN SUNGGAL

SUNGGAL

PER/25/022015.1 1

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

35

1500000000269

PUSKESMAS PADANG BULAN

JL JAMIN GINTING

PER/25/022015.1 2

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

36

1500000000268

PUSKESMAS PASAR MERAH

HM JONI

PER/25/022015.1 3

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

37

1500000000267

PUSKESMAS PB SELAYANG II

BUNGA WIJAYA KUSUMA

PER/25/022015.1 4

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

38

1500000000266

PUSKESMAS RANTANG

RANTANG

PER/25/022015.1 5

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

39

1500000000265

PUSKESMAS SIMALINGKAR

JL BAWANG RAYA

PER/25/022015.1 6

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

28

1500000000278

PUSKESMAS HELVETIA

JL CEMPAKA PERUMNAS HELVETIA

29

1500000000275

PUSKESMAS KAMPUNG BARU

JL BRIG KATAMSO/PS SENIN

30

1500000000277

PUSKESMAS KEDAI DURIAN

KEDAI DURIAN

31

1500000000276

PUSKESMAS KOTA MATSUM

32

1500000000274

33

MA11222I

8451226

7032005


SM0480



24 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

40

1500000000264

PUSKESMAS SIMPANG LIMUN

JL KEMIRI

PER/25/022015.1 7

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

41

1500000000263

PUSKESMAS SUKARAMAI

JL DENAI

PER/25/022015.1 8

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

42

1500000000262

PUSKESMAS TELADAN

JL SM RAJA

PER/25/022015.1 9

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

43

1500000000261

PUSKESMAS TUNTUNGAN

JL BUNGA MELATI

PER/25/022015.2 0

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

44

1500000000191

RS ADVENT MEDAN

JL GATOT SUBROTO KM 4 MEDAN

4524875

YAYASAN RS ADVENT MEDAN

PER/19/022015

RS.TRAUMA CENTRE

16/02/2015

15/02/2016

45

1500000000190

RS BHAYANGKARA MEDAN

JL.KH WAHID HASYIM NO 1 MEDAN

8215990

POLDA SUMUT

PER/18/022015

RS.TRAUMA CENTRE

12/02/2015

11/02/2016

46

1500000000077

RS ESTOMIHI

JL SISINGAMANGARAJA NO 235

7861771

DR. M SAMOSIR, SP.PD

PER/17/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

47

1400000000125

RS ESTOMIHI

JL. SISINGAMANGARAJA NO 235

7861771

DR. M. SAMOSIR,SP.PD

PER/17/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

48

1500000000077

RS ESTOMIHI

JL SISINGAMANGARAJA NO 235

7861771

DR. M SAMOSIR, SP.PD

PER/09/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

49

1400000000129

RS ISLAM MALAHAYATI

JL. PANGERAN DIPONEGORO NO 2-4

4518766

YAY RS MALAHAYATI

PER/16/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

50

1400000000129

RS ISLAM MALAHAYATI

JL. PANGERAN DIPONEGORO NO 2-4

4518766

YAY RS MALAHAYATI

PER/03/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

51

1500000000208

RS MARTHA FRISKA MULTATULI

JL MULTATULI KOMP MULTATULI INDAH NO 1

4149666

PT KARYA UTAMA SEHAT SEJAHTERA

PER/20/022015

RS.TRAUMA CENTRE

16/02/2015

15/02/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

88813182

YAYASAN PERG TINGGI PRIMA INDONESIA

PER/56/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

88881900

PT GRAMARI PRIMA NUSA

PER/15/012016

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

JL JEND TB SIMATUPANG NO 148 SUNGGAL

8475111

YAYASAN BINA KASIH ABADI

PER/06/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

RSU BINA KASIH

JL JEND TB SIMATUPANG NO 148 SUNGGAL

8475111

YAYASAN BINA KASIH ABADI

PER/07/012015

RS.TRAUMA CENTRE

19/01/2015

31/12/2015

1500000000091

RSU HERNA MEDAN

JL MOJOPAHIT NO 118A MEDAN

4510766

YAY TD PARDEDE FOUNDATION

PER/04/012015

RS.TRAUMA CENTRE

15/01/2015

31/12/2015

57

1500000000091

RSU HERNA MEDAN

JL MOJOPAHIT NO 118A MEDAN

4510766

YAY TD PARDEDE FOUNDATION

PER/05/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

58

1500000000624

RSU MATERNA

JL TEUKU UMAR NO 11 MEDAN

4514222

PT RUMAH SAKIT MATERNA

PER/58/042015

RS.TRAUMA CENTRE

23/04/2015

22/04/2016

59

1400000000124

RSU MITRA SEJATI

JL. AH NASUTION NO. 7 P. MASYHUR MEDAN

7875967

YAY. MITRA SEJATI

PER/18/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

60

1400000000124

RSU MITRA SEJATI

JL. AH NASUTION NO. 7 P. MASYHUR MEDAN

7875967

YAY. MITRA SEJATI

PER/04/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

61

1500000000090

RSU PROF DR BOLONI

JL MONGONSIDI NO 11 MEDAN

4512687

YAY PROF DR BOLONI MARPAUNG

PER/06/012015

RS.TRAUMA CENTRE

19/01/2015

31/12/2015

62

1500000000090

RSU PROF DR BOLONI

JL MONGONSIDI NO 11 MEDAN

4512687

YAY PROF DR BOLONI MARPAUNG

PER/10/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

63

1400000000123

RSU SARI MUTIARA

JL. KAPTEN MUSLIM NO 79 MEDAN

8451812

YAY SARI MUTIARA MEDAN

PER/19/122014

RS.TRAUMA CENTRE

01/02/2015

52

1500000000537

RS ROYAL PRIMA

JL AYAHANDA NO 68 A

53

7-1446503984

RS SILOAM DHIRGA SURYA MEDAN

JL IMAM BONJOL NO 6 MEDAN

54

1500000000089

RSU BINA KASIH

55

1500000000089

56

MA11222I

20111


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

64

1500000000092

RSU SARI MUTIARA

JL KAPTEN MUSLIM NO 79 MEDAN

8451812


PER/08/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

65

1500000000092

RSU SARI MUTIARA

JL KAPTEN MUSLIM NO 79 MEDAN

8451812


PER/19/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

66

1500000000200

RSU VINA ESTETICA

JL SULTAN ISKANDAR MUDA NO 119

4147646

YAYASAN VINA ESTETICA

PER/22/022015

RS.TRAUMA CENTRE

18/02/2015

17/02/2016

67

1500000001551

RSUP HAJI ADAM MALIK

JL BUNGA LAU NO 17 MEDAN

8364581

KEMENTERIAN KESEHATAN RI

PER/57/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

68

7-1375319217

RUMAH SAKIT SETIABUDI

JL MESJID NO 3 TANJUNG REJO MEDAN

DR OTMAN SIREGAR SPOT

PER/14/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

20122

B01- KANTOR CABANG PEMATANGSIANTAR

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000051

BPS SERASI

JL. JEND. A. YANI NO. 179K

28756

TAN ERFI

PER/34/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

2

1400000000051

BPS SERASI

JL. JEND. A. YANI NO. 179K

28756

TAN ERFI

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

3

1500000000249

KLINIK AINON

JL.MEDAN KM 4.5 NO.44

6205667

PAUL PARULIAN PURBA

PER/20/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

4

1500000001829

KLINIK BERSAMA

JL MERDEKA NO.47/67

70532010

DR.TIORI RORIA MAGDALENA

PER/26/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I

21111


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1500000000291

KLINIK KASIH

HUTA II BENDO NAGORI DUSUN ULU KEC. UJUNG PADANG KABUPAETN SIMALUNGUN

72908220

DR. SEVEN APRI H SAMOSIR

PER/21/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

6

1500000000148

KLINIK KELUARGA

JL MEDAN NO.18 KM 4

28951

IR.AGUSTINUS SIANIPAR

PER/16/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

7

1400000000553

KLINIK MURNI

JL MELANTHON SIREGAR NO.206

6204978

APRIMO MP SIBARANI

PER/35/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

8

1400000000527

KLINIK PANDU

JL. SM. RAJA NO. 627 PERDAGANGAN

ANTONIUS

PER/36/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

9

1500000000237

KLINIK PUTERI KEMBAR

DALIL TANI NO.40

62164746

HERDIANA GULTOM

PER/19/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

10

1400000000544

KLINIK PUTRI

JL SISINGAMANGARAJA NO.20 KEL PARAPAT KEC GIRSANG SIPANGAN BOLON

6474965

DR.AMRAN SITUMORANG

PER/37/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

11

1400000000534

KLINIK PUTRI

HUTA II NAGORI BAJA DOLOK KEC TANAH JAWA

76137512

SETI HARTATI AM.KEB

PER/38/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

12

1500000000236

KLINIK RIDHO

JALAN SISINGAMANGARAJA NAGORI BALIMBINGAN KECAMATAN TANAH

64530224

DR. MENTI SIBURIAN

PER/18/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

13

1400000000050

KLINIK SIMA HUSADA

JL. KERTAS CETAK NO. 2A

60004795

ANDRE CHRISTIAN PARSAORAN SIMATUPANG

PER/39/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

14

1400000000050

KLINIK SIMA HUSADA

JL. KERTAS CETAK NO. 2A

60004795

ANDRE CHRISTIAN PARSAORAN SIMATUPANG

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

15

1500000000103

KLINIK SUMBER SEHAT

JALAN KAPTEN TANDEAN BLOK D 8

6574736

DR.IRENE HARTONO

PER/15/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

16

1500000000182

KLINIK VITA MEDISTRA

JL.PATTIMURA NO.11 KEC SIANTAR TIMUR

64731970

DR.JUNETA ZEBUA

PER/17/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1500000001813

PT.PRIMA MEDICA NUSANTARA RS BALIMBINGAN

JL.KOMPLEK RS BALIMBINGAN KECAMATAN TANAH JAWA

21151

70829112

RS BALIMBINGAN

PER/ 25/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

18

1500000001814

PT.PRIMA MEDICA NUSANTARA RS LARAS

JL. BESAR PEKAN BAHAPAL KECAMATAN BANDAR HULUAN

21151

081260963 170

RS LARAS

PER/ 24 /072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

19

1500000001815

PT.PRIMA MEDICA NUSANTARA RS PABATU

JL. DESA KEDAI DAMAR KECAMATAN TEBING TINGGI

RS PABATU

PER/23 /072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

20

1400000000535

RSUD PERDAGANGAN

JL.RAJAMIN PURBA ,SH PERDAGANGAN

70324734

RSUD PERDAGANGAN

PER/29/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

21

1400000000676

RSUD PORSEA

JL. RAJA SIPAKKO NAPITUPULU KEC. PORSEA

61245547

PEMERINTAH KAB. TOBA SAMOSIR

PER/30/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

22

1400000000350

RSUD TUAN RONDAHAIM

KOMP PEMKAB SIMALUNGUN PEMATANG RAYA

331170

RSUD TUAN RONDAHAIM

PER/31/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

23

1400000000289

RUMAH SAKIT TENTARA

JL. GUNUNG SIMANUK MANUK NO. 6

434171

RUMAH SAKIT TENTARA

PER/28/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

24

1400000000289

RUMAH SAKIT TENTARA

JL. GUNUNG SIMANUK MANUK NO. 6

434171

RUMAH SAKIT TENTARA

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

25

1400000000545

RUMAH SAKIT UMUM DAERAH PARAPAT

JL.KOL TPR SINAGA KEC.GIRSANG SIPANGAN BOLON

62054053

RSUD PARAPAT

PER/32/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

26

1400000000343

RUMAH SAKIT UMUM HKBP BALIGE

JL GEREJA NO.17 BALIGE

21043

RSU HKBP BALIGE

PER/33/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

27

1500000000589

RUMAH SAKIT VITA INSANI

JL. MERDEKA NO.329

22520

PT. VITA INSANI SENTRA MEDIKA

PER/22/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

KANTOR CABANG

MA11222I

:

B02- KANTOR CABANG KISARAN


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000608

BPS SARTIKA

JL. BESAR NEGERI LAMA KECAMATAN BILAH HILIR KABUPATEN LABUHAN BATU

081264339 055

MURSYID DALIMUNTE

PER/18/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

2

1400000000608

BPS SARTIKA

JL. BESAR NEGERI LAMA KECAMATAN BILAH HILIR KABUPATEN LABUHAN BATU

081264339 055

MURSYID DALIMUNTE

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1500000000057

BPS VITA SERASI

DUSUN I DESA PETATAL KEC TALAWI KAB BATUBARA

61311291

HAMZAH

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

4

1500000000057

BPS VITA SERASI

DUSUN I DESA PETATAL KEC TALAWI KAB BATUBARA

61311291

HAMZAH

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

1400000000109

KLINIK AMANAH

JL. SEI SILAU TIMUR KEC. BUNTU PANE

7352111

DR. NURHIMSYAH JUNEDI NASUTION

PER/29/122015

RS.TRAUMA CENTRE

01/12/2016

29/12/2016

6

1400000000109

KLINIK AMANAH


7352111


PER/25/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

7

1400000000109

KLINIK AMANAH


7352111


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1400000000606

KLINIK AULIA

DUSUN III DESA SEI SUKA DERAS (KEBUN KOPI) KEC. SEI SUKA KAB. BATUBARA

085297350 468

RITA ADELINA

PER/16/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

9

1400000000606

KLINIK AULIA

DUSUN III DESA SEI SUKA DERAS (KEBUN KOPI) KEC. SEI SUKA KAB. BATUBARA

085297350 468

RITA ADELINA

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1400000000609

KLINIK CENTRAL MEDIKA

JL. ACCESS ROAD INALUM DESA PAKAM RAYA KECAMATAN MEDANG DERAS KABUPATEN BATU BARA

082368310 000

ZULKARNAEN

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1400000000609

KLINIK CENTRAL MEDIKA

JL. ACCESS ROAD INALUM DESA PAKAM RAYA KECAMATAN MEDANG DERAS KABUPATEN BATU BARA

082368310 000

ZULKARNAEN

PER/17/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

12

1400000000607

KLINIK DEWI SARTIKA

JL. BEDAGAI NO. 129 KOTAPINANG KECAMATAN KOTA PINANG KABUPATEN LABUHAN BATU SELATAN

081264339 055

MURSYID DALIMUNTE

PER/19/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT JL. BEDAGAI NO. 129 KOTAPINANG KECAMATAN KOTA PINANG KABUPATEN LABUHAN BATU SELATAN JL. PERINTIS NO. 18 SIMPANG KAWAT DUSUN I KELURAHAN HESSA PERLOMPONGAN KECAMATAN AIR BATU KABUPATEN ASAHAN JL. PERINTIS NO. 18 SIMPANG KAWAT DUSUN I KELURAHAN HESSA PERLOMPONGAN KECAMATAN AIR BATU KABUPATEN ASAHAN

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

081264339 055

MURSYID DALIMUNTE

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

081262861 45

DR PATAR MT PANJAITAN

PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

081262861 45


PER/21/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL. ACCESS ROAD INALUM DESA LALANG KEC. MEDANG DERAS

620213

HARUN

PER/24/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KLINIK KESUMA BANGSA

JL. LINTAS SUMATERA NO. 9 DUSUN I DESA RAHUNING KECAMATAN RAHUNING KABUPATEN ASAHAN

085261585 929

DRG ZANIYAR

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1400000000714



085261585 929

DRG ZANIYAR

PER/30/12/2015

RS.TRAUMA CENTRE

01/12/2016

31/12/2016

19

1400000000714



085261585 929

DRG ZANIYAR

PER/20/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

20

1400000000727

KLINIK MITRA SEHAT

JL. KARTINI NO. 195 KECAMATAN KOTA KISARAN BARAT KABUPATEN ASAHAN

081262861 45


PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1400000000727

KLINIK MITRA SEHAT

JL. KARTINI NO. 195 KECAMATAN KOTA KISARAN BARAT KABUPATEN ASAHAN

081262861 45


PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1400000000718

KLINIK RAKYAT

JL. SM RAJA UJUNG BANDAR KECAMATAN RANTAU SELATAN KABUPATEN LABUHAN BATU

081262861 45


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1400000000718

KLINIK RAKYAT

JL. SM RAJA UJUNG BANDAR KECAMATAN RANTAU SELATAN KABUPATEN LABUHAN BATU

081262861 45


PER/22/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

1500000000677

KLINIK SAUDARA

JL. UTAMA NO. 90 B WONOSARI III KEL. AEK KANOPAN KEC. KUALUH HULU KAB. LABUHAN BATU UTARA

082272368 299

KLINIK SAUDARA

PER/05/042015

RS.TRAUMA CENTRE

22/04/2015

31/12/2015

13

1400000000607

KLINIK DEWI SARTIKA

14

1400000000728

KLINIK ESTOMIHI

15

1400000000728

KLINIK ESTOMIHI

16

1400000000203

KLINIK HARUN

17

1400000000714

18

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1500000000129

MITRA KLINIK DR H AHYAR RANGKUTI

DUSUN 1C DESA KAMPUNG PAJAK KEC NA IX-X

HALIMAH SARI RANI MARPAUNG

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000000129

MITRA KLINIK DR H AHYAR RANGKUTI

DUSUN 1C DESA KAMPUNG PAJAK KEC NA IX-X

HALIMAH SARI RANI MARPAUNG

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

27

1500000000662

PUSKESMAS INDRAPURA

JL. JENDRAL SUDIRMAN NO. 63 BATUBARA

081376616 429

PUSKESMAS INDRAPURA

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

1500000000662

PUSKESMAS INDRAPURA

JL. JENDRAL SUDIRMAN NO. 63 BATUBARA

081376616 429

PUSKESMAS INDRAPURA

PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

29

1500000000663

PUSKESMAS KEDAI SIANAM

JL. H.MUHAMMAD ZEIN DESA KEDAI SIANAM KEC. LIMA PULUH KAB. BATU BARA

081361449 866


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

30

1500000000663


JL. H.MUHAMMAD ZEIN DESA KEDAI SIANAM KEC. LIMA PULUH KAB. BATU BARA

081361449 866


PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

31

1500000000665

PUSKESMAS LABUHAN RUKU

JL. IMAM BONJOL NO.17 KEL. LABUHAN RUKU KEC. TALAWI KAB. BATU BARA

081362061 445


PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

32

1500000000665


JL. IMAM BONJOL NO.17 KEL. LABUHAN RUKU KEC. TALAWI KAB. BATU BARA

081362061 445


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

1500000000675

PUSKESMAS LALANG

JL. ACCES ROAD INALUM DESA LALANG KEC. MEDANG DERAS KAB. BATU BARA

PUSKESMAS LALANG

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

34

1500000000675

PUSKESMAS LALANG

JL. ACCES ROAD INALUM DESA LALANG KEC. MEDANG DERAS KAB. BATU BARA

PUSKESMAS LALANG

PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

35

1500000000676

PUSKESMAS LAUTADOR

KEC. LAUTADOR KAB. BATU BARA

PUSKESMAS LAUTADOR

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

36

1500000000676

PUSKESMAS LAUTADOR

KEC. LAUTADOR KAB. BATU BARA

PUSKESMAS LAUTADOR

PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

37

1500000000666

PUSKESMAS LIMA PULUH

JL. PERINTIS KEMERDEKAAN NO.73 KEL. LIMA PULUH KEC. LIMA PULUH KAB. BATU BARA


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

1500000000666


JL. PERINTIS KEMERDEKAAN NO.73 KEL. LIMA PULUH KEC. LIMA PULUH KAB. BATU BARA


PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

39

1500000000667

PUSKESMAS PAGURAWAN

JL. SUDIRMAN NO.149 KEL.P.DODEK KEC. MEDANG DERAS KAB. BATU BARA

PUSKESMAS PAGURAWAN

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

40

1500000000667

PUSKESMAS PAGURAWAN

JL. SUDIRMAN NO.149 KEL.P.DODEK KEC. MEDANG DERAS KAB. BATU BARA

PUSKESMAS PAGURAWAN

PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

41

1500000000668

PUSKESMAS PEMATANG PANJANG

JL. MEDAN-KISARAN NO.110 DESA PEMATANG PANJANG KEC.AIR PUTIH KAB. BATU BARA

081264704 44


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

42

1500000000668


JL. MEDAN-KISARAN NO.110 DESA PEMATANG PANJANG KEC.AIR PUTIH KAB. BATU BARA

081264704 44


PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

43

1500000000669

PUSKESMAS PETATAL

JL. LINTAS SUMATERA KM. 131 PETATAL KEC. TALAWI KAB. BATU BARA

085275999 784

PUSKESMAS PETATAL

PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

44

1500000000669

PUSKESMAS PETATAL

JL. LINTAS SUMATERA KM. 131 PETATAL KEC. TALAWI KAB. BATU BARA

085275999 784

PUSKESMAS PETATAL

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

45

1500000000670

PUSKESMAS SEI BALAI

JL.PERINTIS KEMERDEKAAN DESA SEI BALAI KEC.SEI BALAI KAB. BATU BARA

082360571 537

PUSKESMAS SEI BALAI

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

46

1500000000670

PUSKESMAS SEI BALAI

JL.PERINTIS KEMERDEKAAN DESA SEI BALAI KEC.SEI BALAI KAB. BATU BARA

082360571 537

PUSKESMAS SEI BALAI

PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

47

1500000000671

PUSKESMAS SEI SUKA

JL.LINTAS SUMATERA DESA SEI SUKA DERAS KEC.SEI SUKA KAB. BATU BARA

PUSKESMAS SEI SUKA

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

48

1500000000671

PUSKESMAS SEI SUKA

JL.LINTAS SUMATERA DESA SEI SUKA DERAS KEC.SEI SUKA KAB. BATU BARA

PUSKESMAS SEI SUKA

PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

49

1500000000672

PUSKESMAS SIMPANG DOLOK

DUSUN I DESA SIMPANG DOLOK KAB. BATU BARA

081361063 456


PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

50

1500000000672


DUSUN I DESA SIMPANG DOLOK KAB. BATU BARA

081361063 456


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

51

1500000000673

PUSKESMAS TANJUNG TIRAM

JL. RAHMADSYAH DESA.SUKA MAJU KEC. TANJUNG TIRAM KAB. BATU BARA

081264222 800


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

52

1500000000673


JL. RAHMADSYAH DESA.SUKA MAJU KEC. TANJUNG TIRAM KAB. BATU BARA

081264222 800


PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

53

1500000000674

PUSKESMAS UJUNG KUBU

JL. BESAR UJUNG KUBU DUSUN IV KAB. BATU BARA

081361006 865


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

54

1500000000674


JL. BESAR UJUNG KUBU DUSUN IV KAB. BATU BARA

081361006 865


PER/04/042015

RS.TRAUMA CENTRE

16/04/2015

31/12/2015

55

1400000000294

RS SETIO HUSODO

JL. SISINGAMANGARAJA NO. 67 KEL. KISARAN TIMUR KEC. KOTA KISARAN TIMUR

44999

MARDI

PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

56

1400000000294

RS SETIO HUSODO

JL. SISINGAMANGARAJA NO. 67 KEL. KISARAN TIMUR KEC. KOTA KISARAN TIMUR

44999

MARDI

PER/26/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

57

1500000001895

RSU AVICENNA

JL. LINTAS SUMATERA SIMPANG SIRANGGONG DAMULI PEKAN KABUPATEN LABUHANBATU UTARA

7672018

TOSIP TANJUNG

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

58

1500000001895

RSU AVICENNA

JL. LINTAS SUMATERA SIMPANG SIRANGGONG DAMULI PEKAN KABUPATEN LABUHANBATU UTARA

7672018

TOSIP TANJUNG

PER/07/082015

RS.TRAUMA CENTRE

03/08/2015

31/12/2015

59

1500000001235

RSU TIGA BERSAUDARA

JL. SIMONIS DUSUN I A DESA KAMPUNG PAJAK KECAMATAN NA IX-X

081360103 239

DR M LATIF SITUMORANG

PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

60

1500000001235

RSU TIGA BERSAUDARA

JL. SIMONIS DUSUN I A DESA KAMPUNG PAJAK KECAMATAN NA IX-X

081360103 239

DR M LATIF SITUMORANG

PER/06/062015

RS.TRAUMA CENTRE

04/06/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

61

1400000000468

RSU WIRA HUSADA

JL. KARTINI NO. 209 KEL. SENDANG SARI KEC. KOTA KISARAN BARAT

42532

DR. DIAH JULIANA NST

PER/27/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

62

1400000000468

RSU WIRA HUSADA

JL. KARTINI NO. 209 KEL. SENDANG SARI KEC. KOTA KISARAN BARAT

42532

DR. DIAH JULIANA NST

PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

63

1500000000541

RSUD KABUPATEN BATU BARA

JL. DATUK KWALA GUNUNG KECAMATAN LIMA PULUH KABUPATEN BATU BARA


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

64

1500000000541


JL. DATUK KWALA GUNUNG KECAMATAN LIMA PULUH KABUPATEN BATU BARA


PER/03/042015

RS.TRAUMA CENTRE

16/01/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

B03- KANTOR CABANG PADANG SIDEMPUAN

NAMA PROVIDER

ALAMAT

1

1500000000532

BALAI PENGOBATAN INSANI

JL MEDAN PADANG DESA AEK MUAL KEC.SIABU

2

1500000000259

DR ADE KURNIAWATHY

JL DESA RIANIATE I KEC MUARA BATANGTORU

3

1500000000179

KLINIK ANANDA

4

1500000000185

5

1400000000584

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

RIANI HARNAS NASUTION

PER/39/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

DR ADE KURNIAWATHY

PER/31/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

JL SIBOLGA-BARUS KM 25 KEL KOLANG NAULI

LAMSERIA NABABAN

PER/28/122014

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

KLINIK DAFFA

JL SUDIRMAN LINGKUNGAN I PASAR SIBUHUAN

DR ELNI RUBIANTI DAULAY

PER/21/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KLINIK HARAPAN BUNDA

JL ELANG NO 35 KELURAHAN AEK MANIS

HJ NURSYAM

PER/13/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

60280900

361450301


SM0480



35 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

6

1400000000585

KLINIK MEDICA

JL MANGARAJA BATANG PANE NO 56 GUNUNG TUA

7

1500000000392

KLINIK RIZKY

JL DESA HAPESONG BARU KEC.BATANG TORU

8

1500000000316

PRAKTEK DOKTER DIAN ASPASIA LIMBONG

JL NUSA INDAH NO 21 PADANG SIDIMPUAN

9

1500000000221

PRAKTEK DOKTER ELISA LIE

10

1400000000579

11

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR.HJ.ZUNAIDAH HASANAH M.KES

PER/18/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

DR MELVA ARWITA LUBIS

PER/35/032015

RS.TRAUMA CENTRE

01/03/2015

31/03/2015

63595343

DR DIAN ASPASIA LIMBONG

PER/34/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

KELURAHAN WEK III BATANGTORU TAPANULI SELATAN

59236760

ELISA LIE

PER/29/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

PRAKTEK DOKTER H LIGAM MA'ARUF LUBIS

JL ABDULLAH UMAR NO 1 KAYU JATI PANYABUNGAN

61652465

DR H.LIGAM MA'ARUF LUBIS

PER/14/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

1400000000581

PRAKTEK DOKTER MARULI TUA SILALAHI

JL OSWALD SIAHAAN NO 36

DR MARULI TUA SILALAHI

PER/16/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

12

1400000000583

PRAKTEK DOKTER RIKKY N HARAHAP

JL R SUPRAPTO NO 70 SIBOLGA

DR RIKKY N HARAHAP

PER/11/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

13

1500000000643

PRAKTEK DOKTER SEMPAKATA KABAN

JL PADANG SIDEMPUAN NO 20 B KM.9 PANDAN

DR SEMPAKATA KABAN

PER/43/022015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

14

1500000000644

PRAKTEK DOKTER SRI FARIDA LESTARI HUTAHAEAN

JL SM RAJA NO 28 LING II PASAR BARU PO MANDUAMAS

DR.SRI FARIDA LESTARI HUTAHAEAN

PER/42/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

15

1400000000580

PRAKTEK DOKTER SRI PRIHATIN K N HARAHAP

JL LINTAS GUNUNGTUA-LANGGA PAYUNG DESA SIHOPUK BARU

DR SRI PRIHATIN K N HARAHAP

PER/17/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

16

1400000000578

PRAKTEK DOKTER SRI WAHYUNI

JL SULTAN HASANUDDIN NO 30 PADANG SIDIMPUAN

DR SRI WAHYUNI

PER/15/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

17

1500000000393

PRAKTEK DOKTER SYAMSIDAR

DESA MENANTI SOSA KEC.HUTARAJA TINGGI

DR SYAMSIDAR

PER/36/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

MA11222I

396746406

62646523

6455987


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

18

1500000000689

PRAKTEK DOKTER YUDIKA KRISTIANA

JL YOSSUDARSO NO 160 GUNUNGSITOLI

DR YUDIKA KRISTIANA

PER/40/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

19

1500000000178

PRAKTEK DR ASRIAL

JL SM RAJA NO 200 PADANGSIDIMPUAN

DR ASRIAL

PER/27/022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

20

1500000000177

PRAKTEK DR MEINI BASYARIAH

JL MERDEKA NO 49 KECAMATAN SIPIROK

DR MEINI BASYARIAH

PER/25/012015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

21

1400000000688

PUSKESMAS AEK HABIL

JL MERPATI NO 58 SIBOLGA SELATAN

DR HOTMAULI HUTAGALUNG MKES

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1400000000690

PUSKESMAS PAROMBUNAN

SAHAT D HUTAJULU

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

23

1400000000689

PUSKESMAS PELABUHAN SAMBAS

JL HORAS UJUNG NO 171 SIBOLGA SAMBAS

DR IVONNA HASFIKA

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

1400000000686

PUSKESMAS PINTU ANGIN

JL OSWALD SIAHAAN NO 53 SIBOLGA UTARA

HOTMAULI MANIK SKM

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

25

1400000000687

PUSKESMAS SAMBAS

JL TONGKOL NO 11 SIBOLGA KOTA

DR JULIATI SISKA

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

1400000000186

RS METTA MEDIKA

JL SUTOYO SISWOMIHARJO NO 34 SIBOLGA

25007

PT METTA MEDIKA

PER/12/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

27

1500000000746

RSU BETHESDA

JL DIPONEGORO NO 360 F KM 3 DESA SAIFALAETE TABALOHO

323316

DR YORIEN SETIA ALFARIANTI LASE

PER/41/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

28

1500000000477

RSU PERMATA MADINA PANYABUNGAN

JL MERDEKA NO 155 PANYABUNGAN KAB MANDAILING NATAL

20279

DR H SAFII SIREGAR,SPOG

PER/37/032015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

29

1500000000690

RSU PERMATA MADINA SIBUHUAN

JL KIHAJAR DEWANTARA

421060

DR.MUSBAR

PER/38/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

31/12/2015

PER/19/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

PEMDA

PER/22/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL RUMAH SAKIT SIPIROK

PEMERINTAH

PER/26/022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

RUMAH SAKIT TK IV 01.07.03

JL JEND SUDIRMAN NO 1 KAB TAPANULI SELATAN

BAGINDA HARAHAP

PER/32/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

RUMKITBAN 01.08.02 SIBOLGA

JL ANGGREK NO 6 SIBOLGA

RUMKITBAN

PER/20/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

DR FERDINAND LUMBAN TOBING NO 5

31

1400000000576

RSUD PANYABUNGAN

JL MERDEKA NO 40 KAYU JATI PANYABUNGAN

20181

32

1400000000344

RSUD SIBUHUAN

JL KI HAJAR DEWANTARA SIBUHUAN

421678

33

1500000000176

RSUD TAPANULI SELATAN

34

1500000000260

35

1400000000586

KODE PROVIDER

AKHIR IKS

01/01/2015

RSUD PANDAN

NO

AWAL IKS

RS.TRAUMA CENTRE

1400000000683

:

TIPE IKS

PER/24/122014

30

KANTOR CABANG

PIMPINAN

362180265

B04- KANTOR CABANG TANJUNG MORAWA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001892

BALAI PENGOBATAN HOMBING

JL. SUDIRMAN NO. 148 NO. 148 DOLOK MASIHUL

085260446 061

DR. JANNES E. SIHOMBING

PER/26/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

2

1500000001892

BALAI PENGOBATAN HOMBING

JL. SUDIRMAN NO. 148 NO. 148 DOLOK MASIHUL

085260446 061

DR. JANNES E. SIHOMBING

PER/36/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

3

1400000000619

BPS KULON PROGO

JL. BATANG KUIS GG. KANDAR NO. 8 DS TELAGA SARI TANJUNG MORAWA

7942321

DR. ARSYAD

PER/33/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

4

1400000000619

BPS KULON PROGO

JL. BATANG KUIS GG. KANDAR NO. 8 DS TELAGA SARI TANJUNG MORAWA

5

1400000000033

BPS KURNIA SEHAT

6

1400000000033

7

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. ARSYAD

PER/20/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

JL. JEND SUDIRMAN LK.02 (DEPAN RS SRI PAMELA)

TAN ERFI

PER/14/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

BPS KURNIA SEHAT

JL. JEND SUDIRMAN LK.02 (DEPAN RS SRI PAMELA)

TAN ERFI

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

1400000000031

BPS MORAWA

JL. MEDAN-LUBUK PAKAM KM. 17

7942361

TAN ERFI

PER/07/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

8

1400000000031

BPS MORAWA

JL. MEDAN-LUBUK PAKAM KM. 17

7942361

TAN ERFI

PER/16/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

9

1400000000412

KLINIK 24 JAM DR. IRVAN DALIMUNTHE

JL. SOEKARNO-HATTA NO. 6 LINGKUNGAN IV PERUMAHAN TAMBANG PERMAI INDAH

23443444

DR. IRVAN DALIMUNTHE

PER/19/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

10

1400000000412

KLINIK 24 JAM DR. IRVAN DALIMUNTHE

JL. SOEKARNO-HATTA NO. 6 LINGKUNGAN IV PERUMAHAN TAMBANG PERMAI INDAH

23443444

DR. IRVAN DALIMUNTHE

PER/18/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

11

7-1240382124

KLINIK ABIZA

DSN II DESAS SILAU RAKYAT KEC. SEI RAMPAH

085359461 777

SAMSINAR

PER/29/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

12

1400000000405

KLINIK ARDIFARMA JAYA

JL. STASIUN DSN II KP. KELING KEC. SEI RAMPAH

441543

DR. DINI ZURIANA

PER/18/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

13

1400000000405

KLINIK ARDIFARMA JAYA

JL. STASIUN DSN II KP. KELING KEC. SEI RAMPAH

441543

DR. DINI ZURIANA

PER/17/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

14

1400000000037

KLINIK HAMIDAH

JL.MEDAN-TJ.MORAWA KM 18,5 GG. PRIBADI

7945983

DIAN SARI

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

15

1400000000037

KLINIK HAMIDAH

JL.MEDAN-TJ.MORAWA KM 18,5 GG. PRIBADI

7945983

DIAN SARI

PER/13/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

MA11222I

7942321

20995


SM0480



39 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1400000000404

KLINIK PRATAMA AFIYAH AMPLAS

JL. PANGLIMA DENAI KOMPLEKS RUKO AMPLAS BLOK A NO. 5

80019975

DRS. H. ARENA TRI JAYA GINTING, MM

PER/20/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

17

1400000000404

KLINIK PRATAMA AFIYAH AMPLAS

JL. PANGLIMA DENAI KOMPLEKS RUKO AMPLAS BLOK A NO. 5

80019975

DRS. H. ARENA TRI JAYA GINTING, MM

PER/19/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

18

1500000001880

KLINIK PRATAMA ESSIVA

JL. PASAR VII NO. 16 DESA TEMBUNG KEC. PERCUT SEI TUAN

20351

7380666

DR. JHONES R. SIPAYUNG

PER/24/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

19

1500000001880

KLINIK PRATAMA ESSIVA

JL. PASAR VII NO. 16 DESA TEMBUNG KEC. PERCUT SEI TUAN

20351

7380666

DR. JHONES R. SIPAYUNG

PER/35/072015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

20

1500000000070

KLINIK PRATAMA KULON PROGO BANGUN SARI

JL. MEDAN-TJ.MORAWA DESA BANGUN SARI

085275246 273

DR. MUHAMMAD ARSHAD

PER/23/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

21

1500000000070



085275246 273

DR. MUHAMMAD ARSHAD

PER/27/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

22

1500000000070



085275246 273

DR. MUHAMMAD ARSHAD

PER/09/012015

RS.TRAUMA CENTRE

01/01/2015

30/06/2015

23

1400000000590

KLINIK PRATAMA MANNA

JL. PERTAHANAN NO. 98 PATUMBAK

DR. JHONI SINAGA

PER/21/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

24

1400000000590

KLINIK PRATAMA MANNA

JL. PERTAHANAN NO. 98 PATUMBAK

DR. JHONI SINAGA

PER/28/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

25

1500000001879

KLINIK PRATAMA MARS

JALAN GALANG DUSUN IA NO. 121 DESA PURWODADI KEC. PAGAR MERBAU

20351

7952511

MARHEN, AMK

PER/25/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

26

1500000001879

KLINIK PRATAMA MARS

JALAN GALANG DUSUN IA NO. 121 DESA PURWODADI KEC. PAGAR MERBAU

20351

7952511

MARHEN, AMK

PER/34/072015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

27

1500000000069

KLINIK PRATAMA PAKAM

JL. MEDAN NO. 38 A LUBUK PAKAM

081265238 15

DR. MUSA TOGI MARPAUNG

PER/22/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

MA11222I


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40 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

28

1500000000069



081265238 15


PER/08/02015

RS.TRAUMA CENTRE

01/01/2015

30/06/2015

29

1500000000069



081265238 15


PER/29/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

30

7-1242107043

KLINIK PUJA

JL. BESAR PETUMBUKAN NO. 12 DS PETUMBUKAN KEC. GALANG

20585

DR. BALBIR SINGH, MD

PER/30/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

31

7-1239985383

KLINIK RAIHAN

MENTENG INDAH BLOK B1 NO. 29 MEDAN

20228

081265410 449

DR.DRG SUCI ERAWATI M.KES

PER/28/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

32

1400000000032

KLINIK TUTUN SEHATI

JL. PASAR BARU KM 17 TJ.MORAWA A NO.2

7945676

SALMIAH ZAKARIA

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

33

1400000000032

KLINIK TUTUN SEHATI

JL. PASAR BARU KM 17 TJ.MORAWA A NO.2

7945676

SALMIAH ZAKARIA

PER/15/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

34

1400000000706

PUSKESMAS ARAS KABU

DESA ARAS KABU KEC. BERINGIN

082167926 514

PER/27/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

35

1400000000719

PUSKESMAS BANDAR BARU

DESA BANDAR BARU KEC. BANDAR BARU

081397941 999

PER/27/01/2016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

36

1400000000721

PUSKESMAS BANDAR DOLOK

DESA BANDAR DOLOK KEC. BANDAR DOLOK

081376670 815

PER/27/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

37

1400000000709

PUSKESMAS BANDAR KHALIPAH

DESA BANDAR KHALIPAH KEC. PERCUT SEI TUAN

081362408 181

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

38

1400000000682

PUSKESMAS BANGUN PURBA

DESA BANGUN PURBA KEC. BANGUN PURBA

085262706 056

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

39

1400000000707

PUSKESMAS BATANG KUIS

BATANG KUIS KEC. BATANG KUIS

081265406 00

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

MA11222I


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41 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

40

1400000000681

PUSKESMAS BIRU-BIRU

DESA BIRU-BIRU KEC. BIRU-BIRU

081262175 005

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

41

1400000000693

PUSKESMAS DALU SEPULUH

DESA DALU X KEC. BERINGIN

081376077 435

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

42

1400000000698

PUSKESMAS DELI TUA

DESA DELI TUA KEC. PATUMBAK

081264320 15

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

43

1400000000684

PUSKESMAS GALANG

JL. BUKIT BARISAN GALANG KOTA KEC. GALANG

081265876 80

PER/27/01/2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

44

1400000000703

PUSKESMAS GUNUNG MERIAH

DESA GUNUNG MERIAH KEC. GUNUNG MERIAH

081397999 343

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

45

1400000000711

PUSKESMAS HAMPARAN PERAK

DESA HAMPARAN PERAK KEC. HAMPARAN PERAK

082160351 011

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

46

1400000000722

PUSKESMAS KARANG ANYER

DESA KARANG ANYER KEC. KARANG ANYER

081272118 888

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

47

1400000000720

PUSKESMAS KENANGAN

DESA KENANGAN KEC. PERCUT SEI TUAN

085358348 281

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

48

1400000000723

PUSKESMAS KOTA DATAR

DESA KOTA DATAR KEC. KOTA DATAR

082164747 266

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

49

1400000000726

PUSKESMAS KUTALIMBARU

DESA KUTALIMBARU KEC. KUTALIMBARU

081361326 400

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

50

1400000000710

PUSKESMAS LABUHAN DELI

DESA LABUHAN DELI KEC. LABUHAN DELI

081269230 222

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

51

1400000000705

PUSKESMAS LUBUK PAKAM

JL. DIPONEGORO GG. WAKAF KEC. LUBUK PAKAM

085276730 440

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

MA11222I


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42 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

52

1400000000697

PUSKESMAS MULIOREJO

DESA MULIOREJO KEC. SUNGGAL

081375333 643

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

53

1400000000699

PUSKESMAS NAMORAMBE

DESA NAMORAMBE KEC. NAMORAMBE

081264262 444

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

54

1400000000704

PUSKESMAS PAGAR JATI

DESA PAGAR JATI KEC. LUBUK PAKAM

081265884 10

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

55

1500000000029

PUSKESMAS PANCUR BATU

DESA PANCUR BATU KEC. PANCUR BATU

082168463 332

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

56

1400000000700

PUSKESMAS PANTAI LABU

DESA PANTAI LABU KEC. PANTAI LABU

081263587 546

PER/27/01/2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

57

1400000000694

PUSKESMAS PATUMBAK

DESA PATUMBAK KEC. PATUMBAK

085275960 879

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

58

1500000000030

PUSKESMAS PEMATANG JOHAR

DESA PEMATANG JOHAR KEC.PEMATANG JOHAR

082160580 199

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

59

1500000000031

PUSKESMAS PETUMBUKAN

DESA PETUMBUKAN KEC. PETUMBUKAN

081264151 51

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

60

1400000000724

PUSKESMAS SEI MENCIRIM

DESA SEI MENCIRIM KEC. SUNGGAL

081370221 459

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

61

1400000000702

PUSKESMAS SEI SEMAYANG

JL. SEI MENCIRIM GG. PUSKESMAS KEC. SUNGGAL

081160754 20

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

62

1400000000680

PUSKESMAS SIBOLANGIT

DESA SIBOLANGIT KEC. SIBOLANGIT

081264202 97

PER/27/01/2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

63

1400000000725

PUSKESMAS SUKARAYA

DESA SUKARAYA KEC. SUKARAYA

081265013 29

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

MA11222I


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43 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

64

1400000000701

PUSKESMAS TALUN KENAS

DESA TALUN KENAS KEC. TALUN KENAS

081375190 502

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

65

1400000000685

PUSKESMAS TANJUNG MORAWA

KEL. TANJUNG MORAWA PEKAN KEC. TANJUNG MORAWA

081375253 099

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

66

1400000000708

PUSKESMAS TANJUNG REJO

DESA TANJUNG REJO KEC. PERCUT SEI TUAN

081264209 777

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

67

1400000000678

PUSKESMAS TIGA JUHAR

DESA TIGA JUHAR KEC. STM HULU

081265818 732

PER/27/01/2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

68

1500000000205

RS BHAYANGKARA TK.III TEBING TINGGI

JL. PAHLAWAN NO. 17 TEBING TINGGI

POLRI RI

PER/14/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2017

69

1400000000030

RS GRAND MEDISTRA

JL. MEDAN-LUBUK PAKAM KM.25 NO. 66

7955114

DRS. JOHANNES S

PER/03/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

70

1400000000030

RS GRAND MEDISTRA

JL. MEDAN-LUBUK PAKAM KM.25 NO. 66

7955114

DRS. JOHANNES S

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

71

1500000001957

RS MORAWA UTAMA

JL. MEDAN - TJ.MORAWA KM. 18,5

20351

7945058

PT. MORAWA UTAMA

PER/40/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

72

1500000001957

RS MORAWA UTAMA

JL. MEDAN - TJ.MORAWA KM. 18,5

20351

7945058

PT. MORAWA UTAMA

PER/12/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

73

1400000000589

RS PATAR ASIH

JL. BAKARAN BATU DSN MANGGIS NO. 45 DESA TUMPATAN BERINGIN

7950449

NATANIEL P. NAINGGOLAN, SH

PER/06/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

74

1400000000589

RS PATAR ASIH

JL. BAKARAN BATU DSN MANGGIS NO. 45 DESA TUMPATAN BERINGIN

7950449

NATANIEL P. NAINGGOLAN, SH

PER/31/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

75

1500000001981

RS SRI PAMELA

JL. JEND. SUDIRMAN NO. 299

24748

PT. SRI PAMELA MEDIKA NUSANTARA

PER/37/092015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

24748

PT. SRI PAMELA MEDIKA NUSANTARA

PER/11/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

20362

7944796

PTPN II (PERSERO)

PER/01/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

20362

7944796

PTPN II (PERSERO)

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL. BALAI KOTA NO. 2

21476

DR. DJOHAN ZEIN

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

RSU HERNA

JL. BALAI KOTA NO. 2

21476

DR. DJOHAN ZEIN

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1400000000622

RSU MELATI PERBAUNGAN

JL. DELI NO. 105-115 PERBAUNGAN

7990056

DR. TONDY

PER/25/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

82

1400000000622

RSU MELATI PERBAUNGAN

JL. DELI NO. 105-115 PERBAUNGAN

7990056

DR. TONDY

PER/07/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

83

1400000000587

RSU MITRA SEHAT

JL. SEI MERAH NO. 300 DESA DAGANG KERAWANG

77607489

DR. SUSI, MKT

PER/23/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

84

1400000000587

RSU MITRA SEHAT

JL. SEI MERAH NO. 300 DESA DAGANG KERAWANG

77607489

DR. SUSI, MKT

PER/05/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

85

1400000000620

RSU SARI MUTIARA LUBUK PAKAM

JL. MEDAN NO. 17 LUBUK PAKAM

7951339

DRS. WASHINGTON PURBA

PER/04/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

86

1400000000620

RSU SARI MUTIARA LUBUK PAKAM

JL. MEDAN NO. 17 LUBUK PAKAM

7951339

DRS. WASHINGTON PURBA

PER/32/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

87

1500000000099

RSU SEMBIRING DELI TUA

JL. BESAR NO. 77 DELI TUA

7030802

DRS. JOHANNES S

PER/26/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

76

1500000001981

RS SRI PAMELA

JL. JEND. SUDIRMAN NO. 299

77

1400000000038

RSU DR.GL TOBING PTPN II

JL.RAYA MEDAN-TJ.MORAWA KM 16,5

78

1400000000038

RSU DR.GL TOBING PTPN II

JL.RAYA MEDAN-TJ.MORAWA KM 16,5

79

1400000000035

RSU HERNA

80

1400000000035

81

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

88

1500000000099



7030802

DRS. JOHANNES S

PER/10/012015

RS.TRAUMA CENTRE

01/01/2015

30/06/2015

89

1500000000099



7030802

DRS. JOHANNES S

PER/08/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

90

1500000000248

RSUD DELI SERDANG

JL. THAMRIN LUBUK PAKAM

7952068

PEMKAB DELI SERDANG

PER/12/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

91

1500000000248

RSUD DELI SERDANG

JL. THAMRIN LUBUK PAKAM

7952068

PEMKAB DELI SERDANG

PER/09/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

92

1500000000204

RSUD SULTAN SULAIMAN

JL. NEGARA KM 58 NO. 315 SEI RAMPAH

PEMKAB SERDANG BEDAGAI

PER/13/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

93

1500000000204

RSUD SULTAN SULAIMAN

JL. NEGARA KM 58 NO. 315 SEI RAMPAH

PEMKAB SERDANG BEDAGAI

PER/10/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

B05- KANTOR CABANG MEDAN BELAWAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000054

BALAI PENGOBATAN DELIMA

JL.MEDAN BELAWAN KM 21.5 MEDAN

NURDELIMA SIHOMBING

PER/24/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

2

1500000000054

BALAI PENGOBATAN DELIMA

JL.MEDAN BELAWAN KM 21.5 MEDAN

NURDELIMA SIHOMBING

PER/08/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1500000000053

KLINIK AZIZI

JL.TEMPULING NO.111 A MEDAN

DR.ANITAWATI

PER/29/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000000053

KLINIK AZIZI

JL.TEMPULING NO.111 A MEDAN

DR.ANITAWATI

PER/05/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

1500000001219

KLINIK BINA SEJAHTERA

JL.K.L YOS SUDARSO NO.68

DISIPLIN ROSALINA G

PER/08/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

6

1500000001219

KLINIK BINA SEJAHTERA

JL.K.L YOS SUDARSO NO.68

DISIPLIN ROSALINA G

PER/09/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7

1400000000331

KLINIK CITRA MEDIKA

JL.PLATINA RAYA NO.58 MEDAN

DR.YUDA PRAYOGI

PER/04/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1400000000331

KLINIK CITRA MEDIKA


DR.YUDA PRAYOGI

PER/25/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

9

1400000000331

KLINIK CITRA MEDIKA


DR.YUDA PRAYOGI

PER/25/122014

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

10

1500000000231

KLINIK DANDY

JALAN RUMAH POTONG HEWAN NO.15 A

20241

66516974

SITI HAWA MANAO

PER/26/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

11

1500000000231

KLINIK DANDY

JALAN RUMAH POTONG HEWAN NO.15 A

20241

66516974

SITI HAWA MANAO

PER/01/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000000250

KLINIK HAJI KRAKATAU

JALAN KRAKATAU NO.48 A/110 MEDAN

TAKBIR SIREGAR

PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

13

1500000000250

KLINIK HAJI KRAKATAU

JALAN KRAKATAU NO.48 A/110 MEDAN

TAKBIR SIREGAR

PER/11/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

7-1135974186

KLINIK HAJI MEDAN KRAKATAU

JL KRAKATAU NO 48 A / 110 MEDAN

TAKBIR SIREGAR

PER/11/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

1500000000251

KLINIK HAJI MEDAN PANCING

JALAN WILLIEM ISKANDAR /PANCING NO.100 C

TAKBIR SIREGAR

PER/10/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

20241


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1500000000251

KLINIK HAJI MEDAN PANCING

JALAN WILLIEM ISKANDAR /PANCING NO.100 C

TAKBIR SIREGAR

PER/03/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

17

1500000000052

KLINIK HELVETIA III

JL.KL YOS SUDARSO SP.KANTOR

TEGUH SUHARTO

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

18

1500000000052

KLINIK HELVETIA III

JL.KL YOS SUDARSO SP.KANTOR

TEGUH SUHARTO

PER/06/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

19

1500000000051

KLINIK HELVETIA VIII

JL.KL YOS SUDARSO KM 20,5 MEDAN

TEGUH SUHARTO,SE

PER/22/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

20

1500000000051

KLINIK HELVETIA VIII

JL.KL YOS SUDARSO KM 20,5 MEDAN

TEGUH SUHARTO,SE

PER/07/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1500000000459

KLINIK MUTIARA KOTA BANGUN

JL KL YOS SUDARSO KM 10.5

20241

96333303

NURHAYATI PURBA

PER/05/032015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

22

1500000000459

KLINIK MUTIARA KOTA BANGUN


20241

96333303

NURHAYATI PURBA

PER/02/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

7-1919381394

KLINIK PRATAMA HARAPAN SEHAT SEJAHTERA

JL MARELAN RAYA BESI PUTIH MEDAN KEL TANAH ENAM RATUS

20245

WENDY

PER/02/022016

RS.TRAUMA CENTRE

05/02/2016

31/12/2016

24

7-1919381394

KLINIK PRATAMA HARAPAN SEHAT SEJAHTERA

JL MARELAN RAYA BESI PUTIH MEDAN KEL TANAH ENAM RATUS

20245

WENDY

PER/02/022016

RS.TRAUMA CENTRE

04/02/2016

31/01/2017

25

7-1918653373

KLINIK PRATAMA MEDAN DELI INDONESIA

JL KL YOS SUDARSO NO 109 A KEL TANJUNG MULIA KEC MEDAN DELI

20241

DR JOHNY HENDRIK

PER/01/022016

RS.TRAUMA CENTRE

05/02/2016

31/12/2016

26

7-1918653373

KLINIK PRATAMA MEDAN DELI INDONESIA

JL KL YOS SUDARSO NO 109 A KEL TANJUNG MULIA KEC MEDAN DELI

20241

DR JOHNY HENDRIK

PER/01/022016

RS.TRAUMA CENTRE

04/02/2016

31/01/2017

27

1400000000332

KLINIK TIMUR JAYA

JL.KL.YOS SUDARSO KM 10,6 MEDAN

DR.KURNIAWAN

PER/21/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


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48 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

28

1400000000332

KLINIK TIMUR JAYA


DR.KURNIAWAN

PER/12/122014

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

29

1400000000332

KLINIK TIMUR JAYA


DR.KURNIAWAN

PER/03/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

30

1500000000289

PUSKESMAS BELAWAN

JL MEDAN BELAWAN

DINKES KOTA MEDAN

PER/01/022015

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

31

1500000000287

PUSKESMAS BINJAI

JL. M. NAWI HARAHAP MEDAN

DINKES KOTA MEDAN

PER/01/022015.0 3

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

32

1500000000288

PUSKESMAS BROMO

JL BROMO

DINKES KOTA MEDAN

PER/01/022015.0 2

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

33

1500000000286

PUSKESMAS DENAI

JL DENAI MEDAN

DINKES KOTA MEDAN

PER/01/022015.0 4

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

34

1500000000311

PUSKESMAS DESA TERJUN

JL.KL YOS SUDARSO MEDAN

DR.SURYA SYAHPUTRA PULUNGAN

PER/01/022015.1 1

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

35

1500000000285

PUSKESMAS GLUGUR DARAT

JL PENDIDIKAN MEDAN

DINKES KOTA MEDAN

PER/01/022015.0 5

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

36

1500000000283

PUSKESMAS GLUGUR KOTA

JL KL YOS SUDARSO

6942329

DINKES KOTA MEDAN

PER/01/022015.0 7

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

37

1500000000284

PUSKESMAS MANDALA

JL CUCAK RAWA MEDAN

7351781

DINKES KOTA MEDAN

PER/01/022015.0 6

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

38

1500000000312

PUSKESMAS MARTUBUNG

JL.MARTUBUNG

4520331

DR,NURAISYAH HASIBUAN

PER/01/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2020

39

1500000000304

PUSKESMAS MEDAN AREA SELATAN

JL.MEDAN AREA SELATAN

4520331

DR.LININIATY DAELY

PER/01/022015.1 8

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

MA11222I

4520331

4520331


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4520331

DR.NURLELIN

PER/01/022015.1 9

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

JL KL YOS SUDARSO SP KANTOR MEDAN

6856738

DINKES KOTA MEDAN

PER/01/022015.0 8

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

PUSKESMAS PB SERING

JL.SERING MEDAN TEMBUNG

4520331

DR.REFRINI

PER/01/022015.1 4

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

1500000000281

PUSKESMAS PEKAN LABUHAN


6856738

DINKES KOTA MEDAN

PER/01/022015.0 9

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

44

1500000000306

PUSKESMAS PULO BRAYAN

JL.KL YOS SUDARSO

4520331

NURAISYAH HASIBUAN

PER/01/022015.1 6

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

45

1500000000305

PUSKESMAS SEI AGUL

JL.KEMIRI MEDAN

4520331

DRG IVA PURNAMA

PER/01/022015.1 7

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

46

1500000000310

PUSKESMAS SENTOSA BARU

JL.SENTOSA BARU MEDAN

4520331

DR.SYARIFAH HANUM

PER/01/022015.1 2

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

47

1500000000307

PUSKESMAS TEGAL SARI

JL.RAWA CANGKUK MEDAN

4520331

ERNA SARI

PER/01/022015.1 5

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

48

1500000000309

PUSKESMAS TITI PAPAN

JL.PLATINA IV NO.10 MEDAN

4520331

DR.ERNA SARI

PER/01/022015.1 3

RS.TRAUMA CENTRE

24/02/2015

23/02/2020

49

1400000000336

RS MARTHA FRISKA

JALAN KL YOS SUDARSO NO.91 MEDAN

RASIN BBA,MHA

PER/14/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

50

1400000000336

RS MARTHA FRISKA


RASIN BBA,MHA

PER/19/122014

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

51

1400000000336

RS MARTHA FRISKA


RASIN BBA,MHA

PER/19/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

40

1500000000303

PUSKESMAS MEDAN DELI

41

1500000000282

PUSKESMAS MEDAN LABUHAN

42

1500000000308

43

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

52

1400000000455

RSU MITRA MEDIKA

JL KL YOS SUDARSO KM 7.5 TJ MULIA

DR. HANIFAH, M. KES

PER/15/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

53

1400000000455

RSU MITRA MEDIKA

JL KL YOS SUDARSO KM 7.5 TJ MULIA

DR. HANIFAH, M. KES

PER/27/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

54

1400000000335

RUMAH SAKIT IMELDA

JALAN BILAL NO.24 P.BRAYAN

DR.IMELDA LIANA RITONGA

PER/28/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

55

1400000000335

RUMAH SAKIT IMELDA

JALAN BILAL NO.24 P.BRAYAN

DR.IMELDA LIANA RITONGA

PER/13/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

56

1400000000334

RUMAH SAKIT PELABUHAN BELAWAN

JL.STASIUN NO.92 BELAWAN

6941927

PT.PELABUHAN INDONESIA

PER/12/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

57

1400000000334

RUMAH SAKIT PELABUHAN BELAWAN

JL.STASIUN NO.92 BELAWAN

6941927

PT.PELABUHAN INDONESIA

PER/20/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

58

1500000000452

RUMAH SAKIT TK II PUTRI HIJAU

JALAN PUTRI HIJAU NO.17 MEDAN

PER/07/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

B06- KANTOR CABANG BINJAI

NAMA PROVIDER

ALAMAT

1

1500000000067

BPS SARANA

JL BINJAI KM 11.7 NO 57 DESA PUJIMULYO SUNGGAL

2

1500000000922

KLINIK ADISMA HUSADA

JL TANJUNG PURA-PELAWI UTARA PANGKALAN BRANDAN

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

DR KIKIE INDRIATY

TIPE IKS

AWAL IKS

AKHIR IKS

PER/01/012016

RS.TRAUMA CENTRE

27/01/2016

31/12/2016

PER/04/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

1400000000210

KLINIK ADISMA MANDIRI

JL MEDAN BINJAI KM 10.8 DESA PAYA GELI SUNGGAL

DR BUDI JEFRI

PER/08/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

4

1400000000209

KLINIK MUTIARA DISKI

JL BINJAI KM 12 DESA MULIOREJO KEC SUNGGAL

DRS WASHINGTON

PER/017/082015

RS.TRAUMA CENTRE

01/06/2015

31/12/2016

5

1500000001924

KLINIK PRATAMA SEHAT SEHATI

JL RAYA BINJAI KM 14.6 DISKII

20351

DR ELVII SUSANTI SITEPU

PER/019/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

6

7-1958871584

KLINIK PRATAMA DOA IBU

JL SUDIRMAN LINGK II SETIA NO 53 PERDAMAIAN

20811

H BUDIANTO WAHYU WARDOYO

PER/03/022016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

7

1500000000430

KLINIK PRATAMA SARI MUTIARA TANDEM

JL TANJUNG PURA NO 98 DESA TANDEM HILIR HAMPARAN PERAK

DR TUAHMAN

PER/02/032015

RS.TRAUMA CENTRE

24/03/2015

23/03/2016

8

7-1958581253

KLINIK UTAMA MENTARI

JL T AMIR HAMZAH KEL KWALA LANGKAT

EMA PURNAMA

PER/02/022016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

9

1500000000213

RS BANGKATAN PTPN II

JL SULTAN HASANUDDIN NO 40 BINJAI

75080063

PTPN II

PER/01/022015

RS.TRAUMA CENTRE

18/02/2015

31/01/2016

10

1500000001203

RSIA SYLVANI

JL PERINTIS KEMERDEKAAN NO 21 LK V KEL PAHLAWAN

80045925

DR SUGIANTO

PER/06/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

1500000001944

RSU FULL BETHESDA

JL BINJAI KM 10.8 GG SAMA NO 71 SUNGGAL

20351

65570210

SARMA HARO

PER/015/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

12

1500000001820

RSU FULL BETHESDA

JL BINJAI KM 10.8 / JL SAMA NO 71 SUNGGAL

20351

8457573

SARMA HARO

PER/015/072015

FFS

01/07/2015

30/06/2016

13

1500000000429

RSU KELIAT

JL SULTAN ARAB NO 111 DESA KLUMPANG KAMPUNG HAMPARAN PERAK

PRATEN NATALIA BR KELIAT

PER/03/032015

RS.TRAUMA CENTRE

25/03/2015

24/03/2016

14

1500000001925

RSU RESTU IBU

JL JENDRAL GATOT SUBROTO KM 8.5 NO 434 MEDAN

PER/018/082015

RS.TRAUMA CENTRE

03/08/2015

31/12/2016

MA11222I

370139966

396880292

20761

20111

8451638


SM0480



52 / 322 09-02-2016 18:49:59


NO

KODE PROVIDER

:

C00- KANTOR CABANG PADANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

AWAL IKS

AKHIR IKS

PER/40/092015

RS.TRAUMA CENTRE

08/12/2015

31/12/2016

92544

PER/31/082015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

25552

92544

PER/32/082015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

25552

481291

EDISON SKM MKES

PER/34/082015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

JL SUTAN SYAHRIL NO.332

081363474 133

DR FERI MULYANI

PER/05/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

KLINIK ARUM SARI

JL SUTAN SYAHRIL NO.332

081363474 133

DR FERI MULYANI

PER/44/122015

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

1500000001984

KLINIK FANISA

JL. KAPTEN PIERE TENDEAN NO 4 KAMPUNG BARU

25511

93205

DR YULFI ANETA

PER/39/092015

RS.TRAUMA CENTRE

01/10/2015

31/12/2016

8

1500000001970

KLINIK FITRIA

JL. BY PASS KM 6 SIMPANG PARAK KARAKAH

25161

775322

DR. HJ. AUMAS PABUTI, SPA, MARS

PER/37/092015

RS.TRAUMA CENTRE

01/10/2015

31/12/2016

9

1500000001871

KLINIK INTAN SARI

JL DR H ABDULLAH AHMAD NO 13 01/01 SAWAHAN PADANG TIMUR

25112

DR MARTHA EDDYWATI

PER/26/072015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000000954

KLINIK INTRO MEDIKA

JL H AGUS SALIM NO 19

NURMIDALMI, SE

PER/15/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

11

1500000001941

KLINIK MITRA SENDONA

JL. DR SUTOMO NOMOR 85 KEL KUBU MARAPALAM

CV ARSY HENDRAMA

PER/33/082015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

12

1500000000813

KLINIK SAMUDRA MEDIKA

JL PALEMBANG NO 20 GAUNG

ANI GUSMELA DEWISKA S, SIT

PER/14/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

1

7-885661125

RS SEMEN PADANG

JL. BY PASS KM 7 KEL PISANG KEC PAUH

25161

2

1500000001953

KLINIK AISYIYAH II KAMPUNG PERAK

JL. SM JAMIL KAMPUNG PERAK

25511

3

1500000001955

KLINIK AISYIYAH III

JL PADANG BUKITTINGGI SIMPANG LINTAS LUBUK ALUNG

4

1500000001939

KLINIK AMANAH

JL. RAYA PADANG BUKITTINGGI KM 19 DUKU KEC. BATANG ANAI

5

1400000000040

KLINIK ARUM SARI

6

1400000000040

7

MA11222I

YAYASAN RS SEMEN PADANG

TIPE IKS

811150

25111


SM0480



53 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

13

1500000001025

KLINIK SIMPANG ANDURING

JL ANDALAS SIMPANG ANDURING NO 7 ANDURING KURANJI

14

1500000001954

RS AISYIYAH PARIAMAN

JL. ABDUL MUIS NOMOR 26 TARATAK

15

1500000000635

RS BHAYANGKARA PADANG

JL JATI NO 1 PADANG

16

1500000000767

RS KHUSUS BEDAH KARTIKA DOCTA

JL. GAJAH MADA NO. 14 GUNUNG PANGILUN

17

1500000001054

RS SELAGURI

JL JEND A. YANI NO 26

18

7-797923945

RS SITI RAHMAH

JL. RAYA BY PASS KM. 15 AIE PACAH

19

1400000000039

RS TENTARA REKSODIWIRYO

JL DR WAHIDIN NO.1 PADANG

20

1400000000039

RS TENTARA REKSODIWIRYO

JL DR WAHIDIN NO.1 PADANG

21

7-919921504

RSI IBNU SINA PADANG

JL. GAJAH MADA KEL GUNUNG PANGILUN

22

1500000000955

RSUD DR M ZEIN PAINAN

JL DR A RIVAI KOTA PAINAN

23

1500000001940

RSUD DR RASYDIN PADANG

JL. SEI SAPIH KEC KURANJI

24

1500000001956

RSUD PADANG PARIAMAN

JL. RAYA PADANG BUKITTINGGI KM 42 PARIT MALINTANG

MA11222I

KODE POS

25511

IKS TELEPON

NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PROF DR H ZULKARNAIN ARSYAD, SPPD-KP

PER/17/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PD AISYIYAH KOTA PARIAMAN

PER/30/082015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

POLDA SUMBAR

PER/11/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

H. MUSTAFA KAMAL

PER/12/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

DR HJ HAFLEZIANI M.KES

PER/18/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

YAYASAN RSI SITI RAHMAH

PER/41/092015

RS.TRAUMA CENTRE

04/12/2015

31/12/2016

31003

DATASEMEN KESEHATAN

PER/45/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

31003

DATASEMEN KESEHATAN

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

YAYASAN RS ISLAM SUMATERA BARAT

PER/43/122015

RS.TRAUMA CENTRE

18/12/2015

31/12/2016

PEMDA PESISIR SELATAN

PER/13/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

PEMERINTAH KOTA PADANG

PER/35/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

PEMDA KAB PADANG PARIAMAN

PER/36/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

92544

4481278

25173

25142 214282151 8 25231

PIMPINAN


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS 9111891428

30/04/2016

PER/28/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2016

DR. QUINTA SARI, SP. KK

PER/03/012016

RS.TRAUMA CENTRE

01/04/2016

31/12/2016

31938

DR. QUINTA SARI, SP. KK

PER/09/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

63385109

MAWARDI

PER/10/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

JL PROF M YAMIN SH NO 5

26

1500000001920

RSUP DR M DJAMIL PADANG

JL. PERINTIS KEMERDEKAAN

27

1500000000507

RUMAH SAKIT KHUSUS BEDAH ROPANASURI

JL. AUR NO. 8 PADANG

31938

28

1500000000507

RUMAH SAKIT KHUSUS BEDAH ROPANASURI

JL. AUR NO. 8 PADANG

29

1500000000534

RUMAH SAKIT UMUM BHAKTI KESEHATAN MASYARAKAT (BKM)

JLN JENDRAL SUDIRMAN SAGO KENAGARIAN SAGO-SALIDO KEC IV JURAI

NO

KODE PROVIDER

AKHIR IKS

01/05/2015

RSUD PARIAMAN

:

AWAL IKS

RS.TRAUMA CENTRE

1500000000914

KANTOR CABANG

TIPE IKS

PER/16/052015

25

25111

PIMPINAN

PEMPROV SUMBAR

32371

C01- KANTOR CABANG BUKIT TINGGI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001070

KLINIK ALIF

JL LENGGOGENI NO 92, JORONG LANTAI BATU, NAGARI BARINGIN, LIMA KAUM, TANAH DATAR

EVA YULIA

PER/010/052015

FFS

01/06/2015

31/12/2016

2

1500000001058

KLINIK AQILAH

JL SOEKARNO HATTA KELURAHAN PAKAN SINAYAN, KECAMATAN PAYAKUMBUH BARAT

DR HJ MARISSA

PER/06/052015

FFS

01/06/2015

31/12/2016

3

1500000001059

KLINIK DR H AGUNG MULIA MARS

PERUMAHAN PASAMAN BARU GARDEN BLOK L/4 JORONG KATIMAHA, NAGARI LINGKUANG AUA, KECAMATAN PASAMAN

DR H AGUNG MULIA MARS

PER/09/052015

FFS

01/06/2015

31/12/2016

4

1500000001104

KLINIK KAYYASA ARIFI

JL RAYA PADANG LUA-BUKITTINGGI KM 4, NAGARI PADANG LUA, KEC. BANUHAMPU, AGAM

HERMALIS

PER/011/052015

FFS

01/06/2015

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

5

1500000001949

KLINIK PRATAMA PT AMP PLANTATION

DESA TAPIAN KANDIS, KEC. PALEMBAYAN, KAB. AGAM

6

1500000001161

PRAKTEK DR MARNIYANTI

7

1500000001050

8

KODE POS

IKS TELEPON

PIMPINAN NO IKS

AWAL IKS

AKHIR IKS

PT AMP PLANTATION

PER/013/092015

FFS

01/09/2015

31/08/2016

RAMBAH KINALI. JORONG IV KOTO, KEC. KINALI, PASAMAN BARAT

DR MARNIYANTI

PER/08/052015

FFS

01/06/2015

31/12/2016

PRAKTEK DR SONYA THEMIARTO

JL IMAM BONJOL NO 280, KEL BALAI-BALAI PADANG PANJANG

DR SONYA THEMIARTO

PER/05/052015

FFS

01/06/2015

31/05/2016

1400000000280

PRAKTEK DR SYAHRIL S

JORONG SUDIRMAN, NAGARI MUARO KIAWAI, KEC. GUNUNG TULEH, PASAMAN BARAT

DR SYAHRIL S

PER/015/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1400000000223

RSI IBNU SINA PAYAKUMBUH

JL PEMUDA NO 14 PAYAKUMBUH

92222

YARSI SUMATERA BARAT

PER/013/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1400000000239

RSI IBNU SINA SIMPANG AMPEK

JL M. NATSIR PASAMAN BARU SIMPANG EMPAT PASAMAN BARAT

7464015

YAYASAN RUMAH SAKIT ISLAM SUMATERA BARAT

PER/016/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1400000000239

RSI IBNU SINA SIMPANG AMPEK

JL M. NATSIR PASAMAN BARU SIMPANG EMPAT PASAMAN BARAT

7464015

YAYASAN RUMAH SAKIT ISLAM SUMATERA BARAT

PER/014/072014

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1400000000063

RSUD DR ACHMAD MOCHTAR BUKITTINGGI

JL. DR . A. RIVAI BUKITTINGGI

21720

PEMERINTAH PROVINSI SUMATERA BARAT

PER/014/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000000076

RSUD KOTA PADANG PANJANG

JL BARU TABEK GADANG GANTIANG KOTA PADANG PANJANG

82046

PEMDA PADANG PANJANG

PER/001/012015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

14

1500000000817

RSUD LUBUK BASUNG

JL DR M HATTA, PADANG BARU, LUBUK BASUNG

76017

PEMDA AGAM

PER/003/042015

FFS

01/05/2015

30/04/2017

15

1500000001169

UPTD BALAI LATIHAN KERJA PAYAKUMBUH

JALAN KAMBOJA NO 10 SEBERANG BETUNG PAYAKUMBUH

93632

DASWING SPD

PER/07/052015

FFS

01/06/2015

31/12/2016

KANTOR CABANG

MA11222I

:

26151

TIPE IKS

C02- KANTOR CABANG SOLOK


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000548

BALAI LATIHAN KERJA KABUPATEN SOLOK

JL RAYA LUBUK SELASIH KM 01 KAYU ARO

ZULFAKHRI,S.SOS

PER/03/032015

FFS

02/03/2015

31/12/2015

2

1500000000548

BALAI LATIHAN KERJA KABUPATEN SOLOK

JL RAYA LUBUK SELASIH KM 01 KAYU ARO

ZULFAKHRI,S.SOS

PER/18/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

3

1400000000099

BLUD-RSUD SAWAHLUNTO

JL KARTINI NO 18

74066837

PER/14/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

4

1400000000099

BLUD-RSUD SAWAHLUNTO

JL KARTINI NO 18

74066837

PER/07/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

5

1500000000749

KLINIK ALTHAF

JL M YAMIN NO 83

DR.DINI ASTA DIANI

PER/14/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

6

1500000000749

KLINIK ALTHAF

JL M YAMIN NO 83

DR.DINI ASTA DIANI

PER/12/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

7

1500000000722

KLINIK ARBA

NAGARI SUNGAI RUMBAI TIMUR KEC SUNGAI RUMBAI

YUSNIMAR SST

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

8

1500000000722

KLINIK ARBA

NAGARI SUNGAI RUMBAI TIMUR KEC SUNGAI RUMBAI

YUSNIMAR SST

PER/12/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

9

1500000000761

KLINIK KURNIA

JL DT PERPATIH NAN SABATANG KOTA SOLOK

EVAMAIROZA,SE,M.KES

PER/15/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

10

1500000000761

KLINIK KURNIA

JL DT PERPATIH NAN SABATANG KOTA SOLOK

EVAMAIROZA,SE,M.KES

PER/13/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

11

1500000000948

KLINIK PRATAMA NURJINIS

JL BUKIT BERBUNGA NAGARI SUNGAI RUMBAI TIMUR

NURJINIS

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

12

1500000000948

KLINIK PRATAMA NURJINIS

JL BUKIT BERBUNGA NAGARI SUNGAI RUMBAI TIMUR

NURJINIS

PER/13/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000895

PUSKESMAS ALAHAN PANJANG

KEC LEMBAH GUMANTI KABUPATEN SOLOK

PER/11/052015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

14

1500000000895

PUSKESMAS ALAHAN PANJANG

KEC LEMBAH GUMANTI KABUPATEN SOLOK

PER/16/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

15

1500000000748

PUSKESMAS TALANG

JL LINTAS SOLOK-PADANG KEC GUNUNG TALANG

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

16

1500000000547

RSUD AROSUKA KABUPATEN SOLOK

JL LINTAS SUMATERA AROSUKA KABUPATEN SOLOK

DR.I.NYOMAN ARDANA PUTRA

PER/10/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

17

1500000000547

RSUD AROSUKA KABUPATEN SOLOK

JL LINTAS SUMATERA AROSUKA KABUPATEN SOLOK

DR.I.NYOMAN ARDANA PUTRA

PER/03/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

18

1500000000464

RSUD SIJUNJUNG

JL LINTAS SUMATRA KM 110 TANAH BADANTUANG

20056

PER/08/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

19

1500000000464

RSUD SIJUNJUNG

JL LINTAS SUMATRA KM 110 TANAH BADANTUANG

20056

PER/01/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

20

1400000000017

RSUD SOLOK

SIMPANG RUMBIO KOTA SOLOK

20826

RSUD SOLOK

PER/09/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

21

1400000000017

RSUD SOLOK

SIMPANG RUMBIO KOTA SOLOK

20826

RSUD SOLOK

PER/05/032015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

22

1500000000466

RSUD SUNGAI DAREH

JL LINTAS SUMATERA KM 2 PULAU PUNJUNG

40347

PER/11/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

23

1500000000466

RSUD SUNGAI DAREH

JL LINTAS SUMATERA KM 2 PULAU PUNJUNG

40347

PER/02/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

KANTOR CABANG

MA11222I

:

D00- KANTOR CABANG PEKANBARU KOTA


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

7-129782961

FASKES HATI AKHIR SEPT

2

7-126189943

FASKES KOKOLATE

3

1500000001877

KLINIK FELLITA

JL. KAHARUDDIN NASUTION NO. 145-146 MAHARATU MARPOYAN DAMAI

28111

4

1500000001877

KLINIK FELLITA

JL. KAHARUDDIN NASUTION NO. 145-146 MAHARATU MARPOYAN DAMAI

28111

5

1500000001988

KLINIK FIDYA

6

1500000001988

7

IKS TELEPON

PIMPINAN NO IKS

10150

TIPE IKS

AWAL IKS

AKHIR IKS

SUHESI MAHENDRA

112233

28/09/2015

31/12/2015

NORA

11333

15/09/2015

16/12/2015

68401901

DR. YANTI FATMI, DK

PER/35/072015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

68401901

DR. YANTI FATMI, DK

PER/35/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

JL. LINTAS TIMUR - PASAR SOREK SATU

72026643

DR. IMAN RANDAL TARIGAN, SP.PD

PER/41/102015

RS.TRAUMA CENTRE

05/10/2015

31/12/2015

KLINIK FIDYA

JL. LINTAS TIMUR - PASAR SOREK SATU

72026643

DR. IMAN RANDAL TARIGAN, SP.PD

PER/41/102015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1500000000301

KLINIK NAYAKA HUSADA

JL H IMAM MUNANDAR NO 12 PEKANBARU KEC TANGKERANG SELATAN

68015266

KHAIRUL MAWARDI

PER/12/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

8

1500000001878

KLINIK PELITA HATI

JALAN RAYA TALUK KUANTAN DESA LUBUK SAKAT PERHENTIAN RAJA

28411

76892989

FEBRIAN CHASRA,SE.S.FILL

PER/37/072015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1500000001878

KLINIK PELITA HATI

JALAN RAYA TALUK KUANTAN DESA LUBUK SAKAT PERHENTIAN RAJA

28411

76892989

FEBRIAN CHASRA,SE.S.FILL

PER/37/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

10

1500000000240

KLINIK PERAWANG MEDIKA

KM 6 PERAWANG KEC TUALANG

085364646 865

DR M FAJAR HANAFI

PER/07/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

11

1500000001770

KLINIK PRATAMA BMC PEKANBARU

JL. PAUS NO. 32 F LIMBUNGAN BARU RUMBAI PESISIR

28262

05617614

ARMAINI, SH

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001770

KLINIK PRATAMA BMC PEKANBARU

JL. PAUS NO. 32 F LIMBUNGAN BARU RUMBAI PESISIR

28262

05617614

ARMAINI, SH

PER/31/062015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

JLN SEJAHTERA RAYA NO 5

KODE POS


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

7-492772759

KLINIK PRATAMA CENDANA HUSADA

JL. JATI NO. 76 SENAPELAN

28151

HJ. ELLIYANNORA

PER/46/112015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

7-492772759

KLINIK PRATAMA CENDANA HUSADA

JL. JATI NO. 76 SENAPELAN

28151

HJ. ELLIYANNORA

PER/46/112015

RS.TRAUMA CENTRE

27/11/2015

31/12/2015

15

7-522122673

KLINIK PRATAMA TIFFANY MEDIKA

JL. LINTAS TIMUR BANDAR SEI KIJANG

28383

HERMALINDA

PER/48/112015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

7-522122673

KLINIK PRATAMA TIFFANY MEDIKA

JL. LINTAS TIMUR BANDAR SEI KIJANG

28383

HERMALINDA

PER/48/112015

RS.TRAUMA CENTRE

27/11/2015

31/12/2015

17

1400000000029

KLINIK RAUDAH

JL ADI SUCIPTO NO.239 KEC SIDOMULYO TIMUR/MARPOYAN DAMAI

4881091

DR.GUSRIANTI

PER/06/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

18

1500000000243

RS AMALIA MEDIKA

JL MAHARAJA INDRA NO 433 PANGKALAN KERINCI

95348

H UJANG MALIK SE

PER/09/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

19

1200000000002

RS AWAL BROS

JL JENDRAL SUDIRMAN NO 117

47333

PT AWAL BROS PUTRA

82/IKS/0612

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1400000000036

RS EFARINA

JL.LINTAS TIMUR NO.1

494500

PT EFARINA

PER/10/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

21

1200000000001

RS PROF DR TABRANI

JL SUDIRMAN NO 410

35464

PROF. DR TRABRANI

PER/18/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

22

1400000000100

RS SYAFIRA


3061000

DR IRANA OKTAVIA

13033896716

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

23

1400000000100

RS SYAFIRA


3061000

DR IRANA OKTAVIA

PER/16/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

24

1500000000241

RSUD SIAK SRI INDRAPURA

JL SEI KECIL KABUPATEN SIAK

20012

HJ.ULFAH HANUM

PER/08/032015

RS.TRAUMA CENTRE

28/02/2016

31/12/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

20012

HJ.ULFAH HANUM

PER/08/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

076123954

PT. PERDANA UTAMA MANDIRI

PER/49/122015

RS.TRAUMA CENTRE

07/12/2015

31/12/2016

21718

DEWI KHUSNIATY

PER/21/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

28122

0761 24242

PT. SYIFA UTAMA

PER/45/112015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28122

0761 24242

PT. SYIFA UTAMA

PER/45/112015

RS.TRAUMA CENTRE

27/11/2015

31/12/2015

JALAN LEMBAGA PEMASYARAKATAN NO. 25 GOBAH, PEKANBARU

848100

PT. PEKANBARU MEDIKAL SENTER

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

RUMAH SAKIT PEKANBARU MEDICAL CENTER

JALAN LEMBAGA PEMASYARAKATAN NO. 25 GOBAH, PEKANBARU

848100

PT. PEKANBARU MEDIKAL SENTER

PER/27/062015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1500000000141

RUMAH SAKIT TENTARA PEKANBARU

JL KESEHATAN NO 1 PEKANBARU

22426

DR.YUDHI DORANDES

PER/02/022015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

1500000000141

RUMAH SAKIT TENTARA PEKANBARU

JL KESEHATAN NO 1 PEKANBARU

22426

DR.YUDHI DORANDES

PER/02/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

34

7-131427341

SATYA LENCANA

JLN JOJO NO 2

KOKO

12121111

RS.TRAUMA CENTRE

01/01/2015

02/10/2015

25

1500000000241

RSUD SIAK SRI INDRAPURA

JL SEI KECIL KABUPATEN SIAK

26

7-791544013

RUMAH SAKIT A.YANI

JL. JEND. A. YANI NO. 73

27

1500000001028

RUMAH SAKIT BINA KASIH

JL. SAMANHUDI NO. 3-5 SENAPELAN

28

7-300282953

RUMAH SAKIT ISLAM IBNU SINA

JL. MELATI NO. 60

29

7-300282953

RUMAH SAKIT ISLAM IBNU SINA

JL. MELATI NO. 60

30

1500000001341

RUMAH SAKIT PEKANBARU MEDICAL CENTER

31

1500000001341

32

KANTOR CABANG

MA11222I

:

28115

10150

D01- KANTOR CABANG TANJUNG PINANG


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000014

BALAI PENGOBATAN TIARA MEDIKA

JL. TELUK SASAH TANJUNG UBAN

484427

DR ERIKA M KAMIL

PER/06/022015

RS.TRAUMA CENTRE

24/02/2015

23/02/2016

2

1500000000461

KLINIK ANANDA

JALAN D.I PANJAITAN KM 10

081270276 85

KLINIK ANANDA

PER/17/032015

RS.TRAUMA CENTRE

26/03/2015

25/03/2016

3

1500000001213

KLINIK AZZAHRA

JL. HANG JEBAT KIJANG

KLINIK AZZAHRA

PER/35/042015

RS.TRAUMA CENTRE

27/04/2015

26/04/2016

4

1500000001213

KLINIK AZZAHRA


KLINIK AZZAHRA

PER/35/042015

RS.TRAUMA CENTRE

27/04/2015

26/04/2016

5

1500000001213

KLINIK AZZAHRA


KLINIK AZZAHRA

PER/35/042015

RS.TRAUMA CENTRE

27/04/2015

26/04/2016

6

1500000000924

KLINIK ERNES

JL.PERMAISURI NO.08 TANJUNG UBAN KEPULAUAN RIAU

DR.ODRI ANGNES T

01/05 / ERNES /2015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

7

1500000001281

KLINIK ERNES PT. ALAM INDAH BINTAN

JL. LOT 1-2-3 LAGOI

DR. ODRI ANGNES T

PER/44/062015

RS.TRAUMA CENTRE

11/06/2015

10/06/2016

8

1500000001280

KLINIK ERNES PT. BINTAN LAGOON RESORT

JL. INDERA SEGARA SITE A-12 LAGOI

DR. ODRI ANGNES T

PER/43/062015

RS.TRAUMA CENTRE

11/06/2015

10/06/2016

9

1500000001282

KLINIK MEDIKA YAKESPEN KIJANG

JL. KESEHATAN NO.36 C

DR. REZA FADILAH

PER/45/062015

RS.TRAUMA CENTRE

11/06/2015

10/06/2016

10

1500000000439

KLINIK PARIWISATA LAGOI

KAWASATAN WISATA LAGOI BINTAN . JL KOTA KAPUR

KLINIK PARIWISATA LAGOI

PER/13/032015

RS.TRAUMA CENTRE

10/03/2015

09/03/2016

11

1500000001980

KLINIK PRATAMA KIMIA FARMA D.I PANJAITAN

JLN D.I PANJAITAN KM 9 TANJUNGPINANG

KLINIK PRATAMA KIMIA FARMA D.I PANJAITAN

PER/52/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2016

12

1500000001979

KLINIK PRATAMA KIMIA FARMA GANET

JLN GANET BLOK A NO 1-2 TANJUNGPINANG

KLINIK PRATAMA KIMIA FARMA GANET

PER/53/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

MA11222I

085265696 020

081277692 69 29112


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000001974

KLINIK PRATAMA KIMIA FARMA M.T HARYONO

JLN M.T HARYONO KM 3 TANJUNGPINANG

29113


PER/54/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2016

14

1500000001974


JLN M.T HARYONO KM 3 TANJUNGPINANG

29113


PER/54/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2016

15

1500000000322

PRAKTEK DR. ERWIN BUNTORO

JL PERMAISURI TANJUNG UBAN

DR. ERWIN BUNTORO

PER/09/032015

RS.TRAUMA CENTRE

09/03/2015

08/03/2016

16

1500000000825

PUSKESMAS BATU 10

JL. ADI SUCIPTO KM.10 KEL. BATU IX, KEC. TANJUNG PINANG TIMUR

PUSKESMAS BATU 10

PER/40/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

17

1500000000321

PUSKESMAS KAMPUNG BUGIS

JALAN ABDUL RAHIM KELURAHAN KAMPUNG BUGIS, TANJUNGPINANG


PER/ 10 / 032015

RS.TRAUMA CENTRE

09/03/2015

08/03/2016

18

1500000001526

PUSKESMAS KAWAL

JL. WISATA BAHARI KM 9

PEMERINTAH KAB. BINTAN

PER/46/062015

RS.TRAUMA CENTRE

15/06/2015

14/06/2016

19

1500000001716

PUSKESMAS KIJANG

PUSKESMAS KIJANG

61118

PUSKESMAS KIJANG

PER/48/062015

RS.TRAUMA CENTRE

29/06/2015

28/06/2016

20

1500000000923

PUSKESMAS MEKAR BARU

JL CENDERAWASIH KM 8 TANJUNGPINANG

7003559

RIAMA SARAGI

PER/400/186/5.6. 11/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

21

1500000000638

PUSKESMAS MELAYU KOTA PIRING

JL. KIJANG LAMA BATU 7 KEL. MELAYU KOTA PIRING, KEC. TJ PINANG TIMUR

PUSKESMAS MELAYU KOTA PIRING

PER/34/042015

RS.TRAUMA CENTRE

27/04/2015

26/04/2016

22

1500000001969

PUSKESMAS NUMBING

KP GIN BESAR RT 001 RW 001

29132

PUSKESMAS NUMBING

PER/56/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2016

23

1500000001969

PUSKESMAS NUMBING

KP GIN BESAR RT 001 RW 001

29132

PUSKESMAS NUMBING

PER/56/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2016

24

1500000000823

PUSKESMAS SEI JANG

JL. ARIEF RAHMAN HAKIM KEL. SEI JANG, KEC. BUKIT BESTARI

PUSKESMAS SEI JANG

PER/38/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

MA11222I

29132

26239


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PUSKESMAS TANJUNGPINANG/PANCU R

PER/39/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

085365206 193

PUSKESMAS TELUK SASAH

PER/19/042015

RS.TRAUMA CENTRE

07/04/2015

06/04/2016

081277692 69

PUSKESMAS TELUK SEBONG

PER/12/032015

RS.TRAUMA CENTRE

10/03/2015

09/03/2016

RSUD KABUPATEN BINTAN

PER/37/042015

RS.TRAUMA CENTRE

29/04/2015

28/04/2016

482795

PEMERINTAH PROPINSI KEPRI

PER/11/032015

RS.TRAUMA CENTRE

03/03/2015

02/03/2016

JL SUDIRMAN 795

313000

RSUD KOTA TANJUNGPINANG

PER/18/032015

RS.TRAUMA CENTRE

30/03/2015

29/03/2016

RSUD NATUNA

JL. H.ALI MURTOPO, KABUPATEN NATUNA

31128

RSUD NATUNA

PER/47/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2016

1400000000013

RSUP KEPRI TANJUNGPINANG KM 8

JL. BARU SUNGAI CARANG KM.8 TANJUNGPINANG

PEMERINTAH PROVINSI KEPULAUAN RIAU

PER/05/022015

RS.TRAUMA CENTRE

07/02/2015

06/02/2016

1500000001890

UPTD BALAI LATIHAN KERJA DISNAKERTRANS PROV. KEPRI

JL. DI PANJAITAN KM 8 NO 12

UPTD BALAI LATIHAN KERJA DISNAKERTRANS PROV. KEPRI

PER/14/032015

RS.TRAUMA CENTRE

25/03/2015

24/03/2016

25

1500000000824

PUSKESMAS TANJUNGPINANG/PANCUR

JL. IR. JUANDA NO.1 KEL. KP. BARU, KEC. TANJUNG PINANG BARAT

26

1500000000502

PUSKESMAS TELUK SASAH

JALAN TELUK SASAH LOBAM BINTAN

27

1500000000437

PUSKESMAS TELUK SEBONG

JL RAYA DUKU SUNGAI KECIL

28

1400000000093

RSUD KABUPATEN BINTAN

JL. BAREK MOTOR NO 2B KIJANG

29

1400000000061

RSUD KERPI TANJUNG UBAN

30

1500000000462

RSUD KOTA TANJUNGPINANG

31

1500000001609

32

33

KANTOR CABANG

MA11222I

:

7007758

D02- KANTOR CABANG BATAM NAGOYA


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000048

BATAMINDO INDUSTRIAL PARK KLINIK

JL DADAP BLOK A TOWN CENTER UNIT1-6 BATAMINDO INDUSTRIAL PARK MUKAKUNING BATAM

29433

611907


PER/59/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1400000000048


JL DADAP BLOK A TOWN CENTER UNIT1-6 BATAMINDO INDUSTRIAL PARK MUKAKUNING BATAM

29433

611907


PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

3

1400000000382

BP BATAM VIEW BEACH RESORT

KOMPLEK BATAM VIEW BEACH RESORT JL.HANG LEKIR NONGSA

29466

761740

DR MELATI

PER/62/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1400000000382

BP BATAM VIEW BEACH RESORT

KOMPLEK BATAM VIEW BEACH RESORT JL.HANG LEKIR NONGSA

29466

761740

DR MELATI

PER/11/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

5

1400000000026

BP BUDI ROSARI

JALAN MAHKOTA SIMPANG NO.1 BENGKONG MAHKOTA BATAM

29458

BC GULIMAN MANURUNG

PER/58/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6

1400000000026

BP BUDI ROSARI

JALAN MAHKOTA SIMPANG NO.1 BENGKONG MAHKOTA BATAM

29458

BC GULIMAN MANURUNG

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

7

1400000000595

BP HARAPAN KITA BATU AJI

RUKO CENTRAL MUKA KUNING BLOK A NO.8 BATU AJI

29438

PT AUDY JAYA PRATAMA

PER/47/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2015

8

7-764947233

BP HARAPAN KITA NAGOYA

RUKO DIAN CENTER BLOK F NO 7 NAGOYA BATAM

29432


PER/45/122015

RS.TRAUMA CENTRE

01/12/2015

31/12/2016

9

1400000000025

BP HARAPAN KITA PURI LEGENDA

RUKO PURI LEGENDA BLOK D3 NO.17 BATAM

29464

8096104

YULIANA AMD.KEB SE

PER/04/012015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

10

1400000000025

BP HARAPAN KITA PURI LEGENDA

RUKO PURI LEGENDA BLOK D3 NO.17 BATAM

29464

8096104

YULIANA AMD.KEB SE

PER/50/12015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000000587

BP HARAPAN KITA SUKAJADI

KOMP.RUKO TAMAN NIAGA BLOK N NO.03 SUKAJADI BATAM KOTA

29464

7372056

YULIANA AMD.KEB, SE

PER/51/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000000587

BP HARAPAN KITA SUKAJADI

KOMP.RUKO TAMAN NIAGA BLOK N NO.03 SUKAJADI BATAM KOTA

29464

7372056

YULIANA AMD.KEB, SE

PER/18/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

MA11222I

077836147 5


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

7-769170004

BP HARAPAN KITA VILLA PESONA ASRI

PERUM VILLA PESONA ASRI BLOK A19 NO.10

29433

077880995 68


PER/46/122015

RS.TRAUMA CENTRE

01/12/2015

31/12/2016

14

7-791402413

DELICIA MEDICAL CLINIC

BIDA KABIL BLOK KEMBANG SARI NO 02 KEL KABIL KEC NONGSA

29431

077874972 76

DR. HERLINA DELICIA BONG

PER/49/122015

RS.TRAUMA CENTRE

18/12/2015

31/12/2016

15

1500000000348

KLINIK ALAM SEHAT KABIL

KOMP RUKO TAMAN JASINTA INDAH BLOK A NO 15-16 KEL KABIL KEC NONGSA BATAM

29467

711569

EMMI KRISTIANI SIREGAR

PER/64/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

1500000000348

KLINIK ALAM SEHAT KABIL

KOMP RUKO TAMAN JASINTA INDAH BLOK A NO 15-16 KEL KABIL KEC NONGSA BATAM

29467

711569

EMMI KRISTIANI SIREGAR

PER/17/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

17

1400000000644

KLINIK BATAMEDIKA

KOMPLEK SAMPURNA CENTER BLOK F NO 07 KEL DURIANGKANG KEC SEI BEDUK TANJUNG PIAYU

29437

64212392

DR KRISMADIES M.KKK

PER/48/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

18

1500000000822

KLINIK HUSADATAMA

JL.IMAM BONJOL KOMP.GALAXY NO.3-4 NAGOYA BATAM

29444

431457

DR.KRISMADIES, M.KKK

PER/22/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

19

1500000000822

KLINIK HUSADATAMA

JL.IMAM BONJOL KOMP.GALAXY NO.3-4 NAGOYA BATAM

29444

431457

DR.KRISMADIES, M.KKK

PER/57/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1400000000072

KLINIK MEDIKA

JL R.E MARTADINATA, KOMP WIJAYA BLOK G NO.5 SEKUPANG. BATAM

29425

082389094 888

DR KRISMADIES, M.KKK

PER/08/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

21

1400000000072

KLINIK MEDIKA

JL R.E MARTADINATA, KOMP WIJAYA BLOK G NO.5 SEKUPANG. BATAM

29425

082389094 888


PER/53/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

1400000000466

KLINIK NAYAKA HUSADA 03 KABIL

RUSUNAWA BPJS KETENAGAKERJAAN KABIL

29467

711448

PT NAYAKA ERA HUSADA

PER/12/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

23

1400000000466

KLINIK NAYAKA HUSADA 03 KABIL

RUSUNAWA BPJS KETENAGAKERJAAN KABIL

29467

711448


PER/64/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1400000000074

KLINIK NAYAKA HUSADA 04 NAGOYA

JL RAJA ALI HAJI JODOH KOMP TANJUNG PANTUN BLOK U NO.6 NAGOYA BATAM

29454

457857

DODDY SUDRAJAT

PER/60/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1400000000074

KLINIK NAYAKA HUSADA 04 NAGOYA

JL RAJA ALI HAJI JODOH KOMP TANJUNG PANTUN BLOK U NO.6 NAGOYA BATAM

29454

457857

DODDY SUDRAJAT

PER/09/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

1400000000071

KLINIK PANBIL MEDIKA

KOMP. PERDAGANGAN PANBIL BLOK A NO.9 MUKA KUNING BATAM

29433

371338


PER/52/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

27

1400000000071

KLINIK PANBIL MEDIKA

KOMP. PERDAGANGAN PANBIL BLOK A NO.9 MUKA KUNING BATAM

29433

371338


PER/07/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

28

1500000000821

KLINIK PRIMA HUSADA

KOMPLEK RUKO SMK ALJABAR BLOK B NO.3 BENGKONG INDAH BATAM

29458

61433634

DR.KRISMADIES,M.KKK

PER/56/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

29

1500000000821

KLINIK PRIMA HUSADA

KOMPLEK RUKO SMK ALJABAR BLOK B NO.3 BENGKONG INDAH BATAM

29458

61433634

DR.KRISMADIES,M.KKK

PER/21/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

30

1500000000819

KLINIK PURI SEHAT

RUKO PURI LEGENDA BLOK D3 NO.9 BATAM CENTER

29464

38701249


PER/19/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

31

1500000000819

KLINIK PURI SEHAT

RUKO PURI LEGENDA BLOK D3 NO.9 BATAM CENTER

29464

38701249


PER/54/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

32

1400000000297

KLINIK TAMARA

JL ENGKU PUTRI RUKO TAMAN LAKOTA BLOK F NO 8-9 BATAM CENTER

29464

8097629

DR ANJARI WAHYU WARDHANI

PER/10/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

33

1400000000297

KLINIK TAMARA

JL ENGKU PUTRI RUKO TAMAN LAKOTA BLOK F NO 8-9 BATAM CENTER

29464

8097629

DR ANJARI WAHYU WARDHANI

PER/61/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

34

1500000000820

KLINIK XYSTERA

KOMPLEK GENTA PLAZA BLOK B NO. 5-6 MUKA KUNING BATAM

29439

7293995


PER/20/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

35

1500000000820

KLINIK XYSTERA

KOMPLEK GENTA PLAZA BLOK B NO. 5-6 MUKA KUNING BATAM

29439

7293995


PER/55/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

36

0900000000028

RS AWAL BROS

JL GAJAH MADA KAV I BALOI

431777

DR WIDYA PUTRI

PER/01/012016

RS.TRAUMA CENTRE

11/01/2016

31/03/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

431777

DR WIDYA PUTRI

PER/01/012015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

29432

077845404 4

SRI SOEDARSONO

PER/44/122015

RS.TRAUMA CENTRE

01/12/2015

31/12/2016

JL A YANI NO. 8 MUKA KUNING

29433

371003

PT CAMATHA SAHIDYA

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

RS CAMATHA SAHIDYA

JL A YANI NO. 8 MUKA KUNING

29433

371003

PT CAMATHA SAHIDYA

PER/65/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1300000000017

RS HARAPAN BUNDA

JL SERAYA 01. BATAM

29452

457333

YAYASAN HARAPAN BUNDA

PER/03/012015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

1300000000017

RS HARAPAN BUNDA

JL SERAYA 01. BATAM

29452

457333

YAYASAN HARAPAN BUNDA

PER/66/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

37

0900000000028

RS AWAL BROS

JL GAJAH MADA KAV I BALOI

38

7-768491263

RS BUDI KEMULIAAN BATAM

JL BUDI KEMULIAAN NO.1 SERAYA BATAM

39

0700000000015

RS CAMATHA SAHIDYA

40

0700000000015

41

42

KANTOR CABANG

NO

KODE POS

KODE PROVIDER

:

D03- KANTOR CABANG DUMAI

NAMA PROVIDER

ALAMAT

1

1400000000208

BALAI PENGOBATAN MUTIARA KASIH

JL RAYA LUBUK GAUNG RT 008 SEI SEMBILAN

2

1500000000239

BP AMANAH

JL SOEKARNO HATTA KM 14 BAGAN BESAR

3

1500000000239

BP AMANAH

JL SOEKARNO HATTA KM 14 BAGAN BESAR

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

IR BURJU SIHOMBING

PER / 21 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

28882

DR. DEVY DIANNY

PER/45/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28882

DR. DEVY DIANNY

PER/04/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1400000000024

KLINIK RAWAT INAP TUNAS MUDA MEDIKA

JL WAN DAHLAN IBRAHIM NO 8 DUMAI

28811

439026

DR RAHMI SALBI

PER/16/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

5

1400000000024



28811

439026

DR RAHMI SALBI

PER/47/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6

1400000000024



28811

439026

DR RAHMI SALBI

PER/16/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

7

1500000000623

KLINIK AL UMMI

JL BELIMBING NO.123 KEL RIMBA SEKAMPUNG KEC. DUMAI KOTA

28811

34351

ANDI RONI

PER/17/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

8

1500000000623

KLINIK AL UMMI

JL BELIMBING NO.123 KEL RIMBA SEKAMPUNG KEC. DUMAI KOTA

28811

34351

ANDI RONI

PER/43/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1500000000622

KLINIK AL UMMI SUNGAI SEMBILAN

JL. MAMPU JAYA KEL. TANJUNG PENYEMBAL KEC.SEI SEMBILAN

28813

34351

ANDI RONI

PER/18/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

10

1500000000622

KLINIK AL UMMI SUNGAI SEMBILAN

JL. MAMPU JAYA KEL. TANJUNG PENYEMBAL KEC.SEI SEMBILAN

28813

34351

ANDI RONI

PER/44/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1400000000518

KLINIK ROHIL MEDIKA

JL LINTAS BAGANSIAPIAPI LENGGADAI HILIR KEC RIMBA MELINTANG

28953

MUHAMMAD SYUKRI

PER/48/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000000238

KLINIK SEHATI

JL. PANGERAN DIPONEGORO/SUKAJADI NOMOR 83B

28811

34584

DR. H. SUNARYO

PER/03/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

13

1500000000238

KLINIK SEHATI

JL. PANGERAN DIPONEGORO/SUKAJADI NOMOR 83B

28811

34584

DR. H. SUNARYO

PER/46/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

1500000001416

PKM BAGAN BATU

JL JEND SUDIRMAN NO 562 BAGAN BATU

DINKES KAB ROHIL

PER/28/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

15

1500000001407

PKM BAGAN PUNAK

DESA BAGAN PUNAK

DINKES KAB ROHIL

PER/38/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1500000001391

PKM BAGAN SIAPI-API

JL. JAMBU NO.22 BAGAN SIAPIAPI

DINKES KAB ROHIL

PER/23/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

17

1500000001408

PKM BALAI JAYA

JL LINTAS BAGAN BATU SUMUT

DINKES KAB ROHIL

PER/37/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

18

1500000001405

PKM BANGKO JAYA

JL. LINTAS RIAU-SUMUT KM 12

DINKES KAB ROHIL

PER/24/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

19

1500000001412

PKM BANGKO KANAN

JL ANAS MAAMUN BANGKO KANAN

DINKES KAB ROHIL

PER/32/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

20

1500000001417

PKM BATU HAMPAR

KEC BATU HAMPAR

DINKES KAB ROHIL

PER/27/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

21

1500000000424

PKM BUKIT KAPUR

JL. SOEKARNO HATTA KM 17 KEL BAGAN BESAR

DINAS KESEHATAN KOTA DUMAI

PER/13/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

22

1500000000426

PKM BUKIT KAYU KAPUR

JL. SOEKARNO HATTA KM 27,5 KEL BUKIT KAYU KAPUR


PER/15/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

23

1500000000432

PKM BUKIT TIMAH

KOMP. BTN BUMI DUMAI BARU KEL BUKIT TIMAH


PER/11/03/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

24

1500000000423

PKM BUMI AYU

JL. BUDI UTOMO KEL BUMI AYU


PER/10/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

25

1500000000422

PKM DUMAI BARAT

JL. MH THAMRIN KEL PANGKALAN SESAI


PER/08/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

26

1500000000419

PKM DUMAI KOTA

JL. PATTIMURA KEL.DUMAI KOTA KEC. DUMAI KOTA


PER/06/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

27

1500000000421

PKM JAYAMUKTI

JL. KH NASUTION KEL. JAYA MUKTI


PER/07/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

28

1500000000425

PKM MEDANG KAMPAI

JL. RAYA DUMAI SEI PAKNING KM 11 KEL. TELUK MAKMUR

29

1500000001410

PKM PASIR LIMAU KAPAS

KEC PASIR LIMAU KAPAS

30

1500000001406

PKM PEDAMARAN

JL. LINTAS PEDAMARAN PEKAITAN

31

1500000001413

PKM PUJUD

32

1500000000420

33

KODE POS

IKS TELEPON

PIMPINAN NO IKS

AWAL IKS

AKHIR IKS

PER/14/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PER/34/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

DINKES KAB ROHIL

PER/39/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

JL LINTAS DESA PUJUD

DINKES KAB ROHIL

PER/31/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PKM PURNAMA

JL. TUN SRI LANANG NO.3A KEL. PURNAMA


PER/09/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

1500000001641

PKM RANTAU KOPAR

JL. LINTAS SEKAPAS RANTAU KOPAR

DINKES KAB ROHIL

PKM RANTAU KOPAR

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

34

1500000001418

PKM RANTAU PANJANG KIRI

JL. JEND. SUDIRMAN SIMPANG PELITA

PER/26/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

35

1500000001419

PKM RIMBA MELINTANG

JL. LINTAS BAGAN SIAPIAPI

DINKES KAB ROHIL

PER/25/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

36

1500000001414

PKM SEDINGINAN

JL KH ALIMUDDIN NO 03

DINKES KAB ROHIL

PER/30/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

37

1500000001415

PKM SIMPANG KANAN

JL DESA BAGAN NIBUNG

DINKES KAB ROHIL

PER/29/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

38

1500000001411

PKM SINABOI

JL. LINTAS SINABOI KEPENGHULUAN

PER/33/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

39

1500000000433

PKM SUNGAI SEMBILAN

JL. RAYA DUMAI BASILAM BARU KM 14 KEL. LUBUK GAUNG

PER/12/03/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I


TIPE IKS



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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

40

1500000001409

PKM TANAH PUTIH TJ MELAWAN

JL. LINTAS BAGAN SIAPIAPI-UJUNG TANJUNG

41

1400000000492

RS CAHAYA

JL LINTAS RIAU UJUNG TANJUNG

42

1400000000207

RSUD DR RM PRATOMO

43

1300000000020

44

1300000000020

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DINKES KAB ROHIL

PER/35/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

66818300

DRG CAHAYA PURNAMA SARI

PER/49/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL PAHLAWAN NO 13 BAGAN SIAPIAPI

21731

RSUD DR RM PRATOMO

PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

RSUD DUMAI

JL TANJUNG JATI NO 4

38367

PEMKO DUMAI

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

RSUD DUMAI

JL TANJUNG JATI NO 4

38367

PEMKO DUMAI

PER/50/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28983

D04- KANTOR CABANG RENGAT

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-693615009

KLINIK BUNDA DINDA

JL LINTAS TIMUR UKUI

28382

DR RACHMAD SURYAWAN

PER/16/112015

RS.TRAUMA CENTRE

01/12/2015

31/12/2016

2

7-692702507

KLINIK DINDA

JL LINTAS TIMUR KM 118

28384

DR RACHMAD SURYAWAN

PER/17/112015

RS.TRAUMA CENTRE

01/12/2015

31/12/2016

3

1500000000171

KLINIK DUTA KUANSING MEDIKA

JL. DIPONEGORO NO. 3 TALUK KUANTAN

7642345

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

4

1400000000130

KLINIK MEDISSRA

JL. SULTAN NO. 101 RENGAT

71876761

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

ROHAIDAH


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1400000000263

KLINIK MUIZZAH

JL. RAYA PEMATANG REBA - PEKAN HERAN

DR. LINA Y KIRAM

PER/11/062015

RS.TRAUMA CENTRE

01/08/2015

31/07/2016

6

1400000000262

KLINIK MUIZZAH 2

JL. LINTAS TIMUR SIMP 4 BELILAS

DR. LINA Y KIRAM

PER/12/062015

RS.TRAUMA CENTRE

01/08/2015

31/07/2016

7

1500000000657

KLINIK PRATAMA DR RUDI ARDIAN

JL. JEND. SUDIRMAN - PASIR PENYU

081268681 86

DR. RUDI ARDIAN

PER/08/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

8

7-1200888333

KLINIK PRATAMA DR. IR

JL TELAGA BIRU TEMBILAHAN HULU

29211

00021717

CV INHIL SEHAT BERSAMA

PER/18/122015

RS.TRAUMA CENTRE

29/12/2015

31/12/2016

9

1500000001907

PUSKESAMS LIRIK

DESA LAMBANG SARI LIRIK

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

10

1500000001906

PUSKESMAS AIR MOLEK

JL JEND SUDIRMAN AIR MOLEK

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

11

1500000001897

PUSKESMAS BATANG PERANAP

DESA PERANAP KEC BATANG PERANAP

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

12

1500000001913

PUSKESMAS KAMPUNG BESAR KOTA

JL HANGLEKIR KAMBESKO RENGAT

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

13

1500000001901

PUSKESMAS KILAN

DS BUKIT LUPAI BATANG CENAKU

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

14

1500000001914

PUSKESMAS KUALA CENAKU

DS KUALA CENAKU KEC KUALA CENAKU

29335

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

15

1500000001910

PUSKESMAS KULIM JAYA

DS KULIM JAYA LUBUK BATU JAYA

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

16

1500000001902

PUSKESMAS LUBUK KANDIS

DESA KEPAYANG SARI BATANG CENAKU

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1500000001900

PUSKESMAS PANGKALAN KASAI

JL LINTAS TIMUR SEBERIDA

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

18

1500000001911

PUSKESMAS PEKAN HERAN

DESA PEKAN HERAN KEC RENGAT BARAT

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

19

1500000001898

PUSKESMAS PERANAP

JL PASAR PERANAP KECAMATAN PERANAP

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

20

1500000001904

PUSKESMAS POLAK PISANG

SIMPANG KOTA MEDAN KEC KELAYANG

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

21

1500000001905

PUSKESMAS RAKIT KULIM

DESA PETONGGAM RAKIT KULIM

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

22

1500000001903

PUSKESMAS SEBERIDA

SIMPANG EMPAT BELILAS

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

23

1500000001908

PUSKESMAS SEI LALA

PERKEBUNAN SEI LALA KEC SEI LALA

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

24

1500000001899

PUSKESMAS SENCANO JAYA

KEC BATANG PERANAP

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

25

1500000001912

PUSKESMAS SIPAYUNG

JL HANGTUAH SEKIP HULU KEC RENGAT

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

26

1500000001909

PUSKESMAS SUNGAI PARIT

DESA PASIR BONGKAL SEI LALA

29312

DINAS KESEHATAN

PER/09/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

27

1500000000658

RS INDRAGIRI TEMBILAHAN

JL. TRIMAS NO 77 TEMBILAHAN

PT KENCANA INDRAGIRI MEDIKA

PER/02/012015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

28

1400000000267

RSUD INDRASARI RENGAT

JL. LINTAS TIMUR SUMATRA - RENGAT

DR. IBRAHIM

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

7662247

23555


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

29

1500000000664

RSUD PURI HUSADA TEMBILAHAN

JL VETERAN NO 52 TEMBILAHAN

30

1500000001978

RSUD TELUK KUANTAN

JL KESEHATAN NO. 1 SINAMBEK TALUK KUANTAN

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

IKS TELEPON

PIMPINAN NO IKS

76822118

29511

TIPE IKS

AWAL IKS

AKHIR IKS

PEMKAB INHIL

PER/06/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PEMDA KUANSING

PER/14/102015

RS.TRAUMA CENTRE

15/10/2015

31/12/2016

D05- KANTOR CABANG DURI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000092

BALAI PENGOBATAN DIAN HUSADA

JL. GAJAH MADA NO. 31 SEBANGA DURI

92404

HARIANSYAH

PER/06/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

2

1400000000086

BALAI PENGOBATAN DURI MEDIKA

JL. JEND SUDIRMAN RT/RW 02/05 KEL. BALAI MAKAM DURI

594469

NENNI TRIANA

PER/07/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

3

1500000000412

KLINIK NAYAKA HUSADA DURI

JL DEWI SARTIKA KELURAHAN BALIK ALAM KECAMATAN MANDAU

598085


PER/02/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

4

1500000000413

KLINIK NAYAKA HUSADA II

JALAN HANGTUAH RT 04 RW 01 DESA TAMBUSAI BATANG DUI KECAMATAN MANDAU

560757


PER/03/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

5

7-1704752493

KLINIK PRATAMA BERKAH

JALAN LINTAS DURI – PEKANBARU DESA PINGGIR

AFRIZAL TANJUNG

7-1704752493

RS.TRAUMA CENTRE

02/02/2016

31/12/2016

6

1500000000411

KLINIK PRATAMA HAYATI

JL DURI-DUMAI KM 16 DESA BONCAH MAHANG KECAMATAN MANDAU

71049091

RUSYDI

PER/01/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

7

1500000000593

RSUD KECAMATAN MANDAU

JL. STADION NO. 10 DURI

7038918

RSUD KECAMATAN MANDAU

PER/04/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

28784


SM0480



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Periode : 01012015 s/d 31122016

NO

8

KODE PROVIDER

RUMAH SAKIT PERMATA HATI

1400000000085

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

:

ALAMAT

KODE POS

JL JEND. SUDIRMAN NO 37 KEL GAJAH SAKTI KEC MANDAU DURI

PIMPINAN NO IKS

94902

PT. PERMATA HATI SUKSES MEDIKA

PER/05/042015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/05/2015


D06- KANTOR CABANG PEKANBARU PANAM

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

1500000001036

KLINIK ALKADRIAH

JL HR SUBRANTAS NO 148 SIDOMULYO

2

7-469185283

KLINIK CITRA BUNDA

JL RAYA SUKARAMAI KEC. TAPUNG HULU KAB. KAMPAR

3

1500000000754

KLINIK KELUARGA KITA

JL GARUDA SAKTI KM. 21 DESA BENCAH KELUBI KEC. TAPUNG

4

1500000000766

KLINIK KELUARGA SEHAT DOKTOR BASTIAN

JL GARUDA SAKTI KM 2

5

1500000001032

KLINIK PANJI HUSADA

DESA KABUN KAB. ROKAN HULU

6

1500000001027

KLINIK PRATAMA ANNISA MEDIKA 2

JL. HR. SOEBRANTAS NO 107 PANAM SIDOMULYO BARAT

7

7-329288012

KLINIK PRATAMA DOKTER AMELIA

JL PASIR PUTIH NO. 1 DESA TANAH MERAH KEC. SIAK HULU

28452

8

7-616675225

KLINIK PRATAMA ELLIYA HUSADA

JL DELIMA NO 138 PANAM

28291

PIMPINAN NO IKS

081276480 467

1

MA11222I

IKS TELEPON

TIPE IKS

AWAL IKS

AKHIR IKS

ROMMY ADRIANTO

PER/12/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

HJ ROSINA. SKM

PER/20/112015

RS.TRAUMA CENTRE

19/11/2015

11/11/2016

082311116 191

MULYADI B

PER/08/052015

RS.TRAUMA CENTRE

11/05/2015

10/05/2016

7875077

DR ADOLF BASTIAN TAMBUSAI.M.PD

PER/07/052015

RS.TRAUMA CENTRE

11/05/2015

10/05/2016

ZUSHENI GAYATRI

PER/14/052015

RS.TRAUMA CENTRE

27/05/2015

26/05/2016

081365798 138

HJ. KARTINI. SKM

PER/11/052015

RS.TRAUMA CENTRE

26/05/2015

25/05/2016

076170146 27

DR AMELIA ANGGREINI MILALA

PER/16/112015

RS.TRAUMA CENTRE

12/11/2015

09/11/2016

HJ ELLIYANNORA

PER/22/112015

RS.TRAUMA CENTRE

27/11/2015

24/11/2016

28464


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

9

7-325123713

KLINIK PRATAMA INDO SEHAT PEKANBARU

JL. KAHARUDIN NASUTION NO. 36-39 MARPOYAN DAMAI

10

1500000000538

KLINIK PRATAMA UWA MEDIKA

11

1500000000986

12

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

082288498 728

DR MERY SISCANOVA PUTRI

PER/17/112015

RS.TRAUMA CENTRE

11/11/2015

09/11/2016

JL HR SUBRANTAS NO 92 A-C KEL SIMPANG BARU

7872833

DR DEFRI

PER/04/042015

RS.TRAUMA CENTRE

15/04/2015

14/04/2016

RS AWAL BROS PANAM

JL HR SOEBRANTAS TUAH KARYA

586888

IR ARFAN AWALOEDDIN MARS

PER/10/052015

RS.TRAUMA CENTRE

13/05/2015

12/05/2016

1400000000152

RS AWAL BROS UJUNG BATU

JL. JEND. SUDIRMAN NO. 314 UJUNGBATU

7363329

PT. AWAL BROS INTAN MEDIKA

PER/13/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

13

1500000000646

RS SURYA INSANI

JL. DIPONEGORO KM 4 PASIR PENGARAIAN

7003404

PT.SURYA INSANI

PER/05/042015

RS.TRAUMA CENTRE

22/04/2015

21/04/2016

14

1500000000770

RSIA BUNDA ANISYAH

JL RAYA PEKANBARU BANGKINANG KM 52 AIR TIRIS

081243533 006

DR ANDRI SETIAWAN

PER/09/052015

RS.TRAUMA CENTRE

12/05/2015

11/05/2016

15

1400000000027

RUMAH SAKIT SANSANI

JALAN SOEKARNO HATTA (ARENGKA ATAS) PEKANBARU

564666

SYAHRONI TUA

PER/03/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

KANTOR CABANG

NO

KODE PROVIDER

:

28125

D07- KANTOR CABANG BATAM SEKUPANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000475

BALAI LATIHAN KERJA DUA UTAMA JAYA

JL YOS SUDARSO, KOMP GREENTOWN WAREHOUSE NO 01

495120

M. TABRI

PER/03/032015

RS.TRAUMA CENTRE

27/03/2015

27/03/2016

2

1400000000011

KLINIK ASIA INDAH

RUKO PUTRA JAYA BLOK A NO 10-11

7042991

MARTHEN TANDIRURA

PER/01/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

MA11222I


SM0480



77 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

1500000001972

KLINIK ASIH TIBAN

TIBAN I BLOK D7 NO. 3 KEL. PATAM LESTARI KEC. SEKUPANG

29412

322704

HJ GUSNAWATI

PER/38/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

4

7-1265428985

KLINIK GLOBAL MEDICAL CENTRE

KOMP RUKO TAMAN LAGUNA BLOK A-2 NO 12 SEKUPANG BATAM

29428

077835829 23

RIRIS LIANI

PER/02/012016

RS.TRAUMA CENTRE

05/01/2016

03/01/2017

5

1500000001252

KLINIK HUSADA KARIMUN

JL. AHMAD YANI NO 7-8 KEC. MERAL KABUPATEN KARIMUN

325100

DR JUSRIZAL

PER/36/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6

1500000001253

KLINIK MEDILAB KARIMUN

JL.R.H FISABILILLAH RT/RW 003/004 DESA PANGKE KECAMATAN MERAL TANJUNG BALAI KARIMUN

082391076 669

DR JUSRIZAL

PER/35 /052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000001390

KLINIK TIBAN SEHAT

JL GAJAH MADA RAYA TIBAN LAMA NO 15 RT 01/13 TIBAN LAMA BATAM

081931178 484

DR ADE MEGA JAYANTI

PER/37/062015

RS.TRAUMA CENTRE

17/06/2015

16/06/2016

8

1400000000255

KLINIK VELY

KOMPLEK RUKO FANINDO BLOK A NO 12 A KEL TANJUNG UNCANG

9131737

DR. SITI VERA NOTARINA

PER/01/01/2016

RS.TRAUMA CENTRE

05/01/2016

03/02/2017

9

1400000000132

KLINIK YAHYA MEDICAL CENTER

RUKO SAGULUNG PERMAI BLOK B NO 14-15 BATU AJI

392748

SYARIEF A. FAHMI, ST

PER/03/012016

RS.TRAUMA CENTRE

05/01/2016

03/01/2017

10

1500000000494

PKM TANJUNG BALAI

JL. KARTINI NO.14 TANJUNG BALAI KARIMUN

PER/31/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

11

1500000001982

RS GRAHA HERMINE

JL JEND SOEPRAPTO RUKO ASIH RAYA BLOK B NO 6-15 BATUAJI

MHD INDRA GUNAWAN LUBIS

PER/039/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

12

1000000000005

RS. CHARIS MEDIKA

JL, R, SUPRAPTO BLOK D NO.1 BATU AJI BATAM

DR. JOHANA AQUARISTA

PER/32/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

13

1305070000021

RSUD EMBUNG FATIMAH KOTA BATAM (TRAUMA CENTER)

JL. R.SOEPRAPTO BLOK D NO.1-9 BATU AJI

KOTA BATAM

PER/34/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

KANTOR CABANG

MA11222I

:

29422

21060

29412

363318

364446

E00- KANTOR CABANG JAMBI


SM0480



78 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000660

BLK PROVINSI JAMBI

JL YULIUS USMAN NO 09 PEMATANG SULUR TELANAIPURA

PER / 08 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

2

1500000000523

KLINIK ANANDA JAMBI

JL LINTAS TEBING TINGGI RT 03

PER / 02 / 032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

3

1500000001212

KLINIK TANJUNG LUMUT

JL LINGKAR TIMUR I TANJUNG LUMUT KEL TALANG BAKUNG

PER / 14 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

4

1500000001008

PUSKESMAS AUR DURI

JL AUR DURI NO 1 PERUMNAS VILLA AUR DURI BLOK IB

PER / 13 / 052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

5

1500000000851

PUSKESMAS MERSAM

JL LINTAS JAMBI - MA TEBO KM 102 MERSAM

PER / 11 / 052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

6

1500000000852

PUSKESMAS MUARA TEMBESI

JL JAMBI - MA BUNGO RT 8 KAMPUNG BARU MUARA TEMBESI

PER / 12 / 052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

7

1500000000631

PUSKESMAS OLAK KEMANG

JL K H HASAN ANANG NO 33 DANAU TELUK

PER / 09 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

8

1500000000531

PUSKESMAS PAAL X

JL MARSDA SURYA DARMA KOTA BARU JAMBI

98555604

PER / 03 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

9

1500000000545

PUSKESMAS PAKUAN BARU

JL JENDRAL SUDIRMAN JAMBI SELATAN

744901

PER / 05 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

10

1500000001211

PUSKESMAS PUTRI AYU

JL SLAMET RIYADI NO 02 LGOK

PER / 16 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

11

1500000001243

PUSKESMAS SIMPANG KAWAT

JL HOS COKROAMINOTO KEC JELUTUNG

PER / 17 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

12

1500000000546

PUSKESMAS TAHTUL YAMAN

JL K H TOMOK KEC PELAYANGAN

PER / 06 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

MA11222I

74066247


SM0480



79 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000543

PUSKESMAS TANJUNG PINANG

JL TARUMA NEGARA NO50 KOTA JAMBI

10001415

PER / 04 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

14

1400000000559

RS BHAYANGKARA JAMBI

JL RADEN MATTAHER NO 03

23246

PER / 03 / 012016

RS.TRAUMA CENTRE

20/01/2016

30/11/2016

15

0700000000017

RS DR BRATANATA

JL RD MATTAHER NO 33

20388

PER / 02 / 012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

16

1500000001224

RS RIMBO MEDIKA

JL PATIMURA RT 02 KENALI BESAR

PER / 15 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

17

1400000000560

RS ROYAL PRIMA JAMBI

JL RADEN WIJAYA RT 35 KEBON KOPI

PER / 01 / 012016

RS.TRAUMA CENTRE

20/01/2016

30/11/2016

18

1400000000095

RSUD AHMAD RIPIN

JL LINTAS SUMATERA SENGETI

PERJ/07/042015

RS.TRAUMA CENTRE

21/04/2015

30/03/2016

19

1400000000096

RSUD DAUD ARIF

JL SYARIF HIDAYATULLAH KUALA TUNGKAL

PER / 19 / 082015

RS.TRAUMA CENTRE

21/04/2015

31/12/2015

20

1000000000004

RSUD HAJI ABDOEL MADJID BATOE

JL PROF DR SRI SUDEWI, SH MUARA BULIAN

PER / 18 / 072015

RS.TRAUMA CENTRE

08/04/2015

31/12/2015

21

1400000000250

RSUD NURDIN HAMZAH

JL WR SUPRATMAN MUARA SABAK

81258045

PER / 20 / 082015

RS.TRAUMA CENTRE

09/06/2015

31/12/2015

22

1400000000094

RSUD RADEN MATTAHER JAMBI

LETJEN SUPRAPTO NO 31 TELANAIPURA

61692

PERJ/001/012015

RS.TRAUMA CENTRE

10/01/2015

31/12/2015

23

1500000000850

RSUD SULTAN THAHA SYAIFUDDIN

JL SULTAN THAHA SYAIFUDDIN KM 04

PER / 10 / 052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

KANTOR CABANG

MA11222I

:

RS DR BRATANATA

E01- KANTOR CABANG MUARO BUNGO


SM0480



80 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DINAS SOSIAL TENAGA KERJA DAN TRANSMIGRASI KAB BUNGO

PER/01/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

POLRES MERANGIN

PER/02/042015

RS.TRAUMA CENTRE

09/04/2015

08/04/2017

JL LINTAS SUMATERA KM 04 RT 005 RW 10 DESA SUNGAI ULAK KEC NALO TANTAN

DRG MERRY WAHYUNI

PER/04/042015

RS.TRAUMA CENTRE

24/04/2015

23/04/2016

KLINIK SEHAT KELUARGA CERIA

JL LINTAS SUMATERAKM 15 ARAH PADANG RT 07 DUSUN EMBACANG GEDANG KEC TANAH SEPENGGAL LINTAS

M EFFENDI HARAHAP

PER/08/062015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

1500000000958

KLINIK TC GANDI MEDIKA 5

JL PAHLAWAN KEL WIROTHO AGUNG KEC RIMBO BUJANG

MARLENA HARTATI

PER/05/052015

RS.TRAUMA CENTRE

25/05/2015

26/05/2016

6

1500000001154

KLINIK TC RIMBO MEDICAL CENTER

JLN. PAHLAWAN UNIT 2 (SIMPANG JLN. 10) KEC. RIMBO BUJANG

DR DIDIK AFRIADI MMR

PER/07/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000001149

PUSKEMAS MUKO-MUKO BATHIN VII TC

JL KOMPLEK PERKANTORAN NO 02 TANJUNG AGUNG KEC MUKO-MUKO BATHIN VII

DINAS KESEHATAN KAB BUNGO

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1500000001153

PUSKEMAS RANTAU KELOYANG

RANTAU KELOYANG KEC PELEPAT


PER/05/062016

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1500000001136

PUSKESMAS BABEKO TC

DS BABEKO KEC BATHIN II BABEKO


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000001148

PUSKESMAS BATHIN III TC

DS AIR GEMURUH KEC BATHI III


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

1500000001150

PUSKESMAS BATHIN III ULU TC

DS. MUARA BUAT KEC. BATHIN III ULU


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

12

1500000001140

PUSKESMAS KUAMANG JAYA TC

DS KUAMANG KEC PELEPAT ILIR


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1

1500000000315

BLK KAB MUARA BUNGO

JALAN TAMAN SISWA SKB

2

1500000000520

KLINIK BHAYANGKARA POLRES MERANGIN

JL LINTAS SUMATERA KM 2 KEC BANGKO

3

1500000000634

KLINIK MGC 24 (KLINIK TC)

4

1400000000052

5

MA11222I

21046


SM0480



81 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000001139

PUSKESMAS KUAMANG KUNING I TC

DS KUAMANG JAYA KEC PELEPAT ILIR


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

1500000001138

PUSKESMAS KUAMANG KUNING X TC

JL BHAKTI HUSADA DUSUN MULIA BHAKTI KEC PELEPAT


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

15

1500000001152

PUSKESMAS LIMBUR LUBUK MENGKUANG TC

DS. LIMBUR LB. MENGKUANG KEC LIMBUR LUBUK MENGKUANG


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1500000001147

PUSKESMAS MUARA BUNGO I TC

JL KESUMA MUARA BUNGO KEC PASAR MUARA BUNGO

DINAS KESEHATAN KABUPATEN BUNGO

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

17

1500000001137

PUSKESMAS MUARA BUNGO II

JL DURIAN DS SUNGAI ARANG KEC BUNGO DANI


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

18

1500000001146

PUSKESMAS PELAYANG TC

DS PELAYANG KEC BATHIN II PELAYANG


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

19

1500000001151

PUSKESMAS PULAU BATU TC

DS PULAU BATU KEC JUJUHAN ILIR


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

20

1500000001143

PUSKESMAS RANTAU IKIL TC

DS RANTAU IKIL KEC JUJUHAN


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

21

1500000001141

PUSKESMAS RANTAU PANDAN TC

DS RANTAU PANDAN KEC RANTAU PANDAN


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

22

1500000001144

PUSKESMAS TANAH SEPENGGAL LINTAS TC

JL LINTAS SUMATERA KM 25 ARAH PADANG KEC TANAH SEPENGGAL LINTAS


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

23

1500000001145

PUSKESMAS TANAH SEPENGGAL TC

JL TANAH TUMBUH PASA LUBUK LANDAI KEC TANAH SEPENGGAL


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

24

1500000001142

PUSKESMAS TANAH TUMBUH TC

JL BUKIT HARAPAN KEC TANAH TUMBUH


PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


SM0480



82 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

25

1500000000297

RSU MAYJEN H.A THALIB (TC)

JL JEND BASUKI RAHMAT NO 1 SUNGAI PENUH - PROP JAMBI

26

1400000000053

RSUD CHATIB QUZWAIN SAROLANGUN

JL. LINTAS SUMATERA KM.09 DESA BUKIT,SAROLANGUN

27

1400000000400

RSUD H HANAFIE MUARA BUNGO

JLN TEUKU UMAR NO 68 MUARO BUNGO

28

1500000000588

RSUD KOL ABUNDJANI BANGKO - TC

JL KESEHATAN NO 20 BANGKO

KANTOR CABANG

NO

KODE PROVIDER

:

IKS TELEPON

PIMPINAN NO IKS

21447

21314

TIPE IKS

AWAL IKS

AKHIR IKS

PEMDA KERINCI

PER/08/102015

RS.TRAUMA CENTRE

27/01/2016

30/09/2016

DR IRWAN MISWAR

PER/04/032015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

DR SAFFARUDIN MATONDANG MPH

PER/08/2015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

PEMKAB MERANGIN

PER/03/042015

RS.TRAUMA CENTRE

20/04/2015

19/04/2016

G00- KANTOR CABANG PALEMBANG

NAMA PROVIDER

ALAMAT

1

1500000000930

BP INDRATAMA MEDICA CENTER

JALAN MP MANGKU NEGARA NO.10 RT.002/012 KELURAHAN KALIDONI PALEMBANG

2

1400000000178

BP KESEHATAN KERJA

JL A YANI NO 111 KEL 16 ULU

3

1500000000931

BP REZKY MEDICA

4

1500000001095

5

1500000000929

MA11222I

KODE POS

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/16/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DR WAHYUDI SAHADI

PER/23/062015

RS.TRAUMA CENTRE

26/05/2015

30/04/2016

JALAN TANJUNG SIAPI-API / LETJEN HARUN SOHAR RT.042/010 KELURAH KEBUN BUNGA KECAMATAN SUKARAMI PALEMBANG

WIDIANTI

PER/19/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

BP RIZKY ASYIFA

JL. KAPTEN A RIVAI NO. 80D RT.030/009 KEL 26 ILIR BUKIT KECIL

DR. YESSY

PER/25/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KLINIK DIATARI MEDIKA

JL. MP. MANGKUNEGARA KOMP. PUSRI KEBON SIRIH NO.1 KELURAHAN BUKIT SANGKAL KALIDONI PALEMBANG

FARIDA

PER/18/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016


SM0480



83 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6

1500000000707

KLINIK NAYAKA HUSADA 04

JL. ALAMSYAH SATU PN RT.53/16 KELURAHAN BUKIT LAMA KEC.ILIR BARAT 1

NAYAKA ERA HUSADA

PER/06/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

7

1400000000164


JL BASUKI RAHMAT NO 1676

DR ERDAYANA FATMA

PER/10/042015

RS.TRAUMA CENTRE

07/04/2015

06/04/2016

8

1500000000706

KLINIK NAYAKA HUSADA03

JL SUKABANGUN II A2 RT.006 RW.02

NAYAKA ERA HUSADA

PER/05/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

9

1400000000166

KLINIK OPINA

JL KADIR TKR LR SAILUN NO 1200

DR H TRISNAWARMAN

PER/14/042015

RS.TRAUMA CENTRE

24/04/2015

31/03/2016

10

1500000000493

KLINIK PKU MUHAMMADIYAH PLAJU

JL. KAPTEN ABDULLAH NO. 02 RT.030 KELURAHAN PLAJU ILIR KECAMATAN PLAJU PALEMBANG

DR. YUNIAR SARI (YAYASAN MUHAMMADIYAH)

PER/08/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

11

1400000000177

KLINIK YAZRI

JL MAY ZEN KOMP PT PUSRI PALEMBANG

DR YUDA FETTY P

PER/22/062015

RS.TRAUMA CENTRE

26/05/2015

30/04/2016

12

1500000000962

PUSKESMAS 1 ULU

JL. H. FAQIH USMAN NO. 2329 RT. 43 ULU LAUT, KEC. SEBERANG ULU I

DR.HURRIAH DEWI S. PANJAITAN

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

13

1500000001010

PUSKESMAS 11 ILIR

JL. SLAMET RIADY NO. 455 11 ILIR , KEC. ILIR TIMUR II

DR. H. EZRIN NOER

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

1500000001010

PUSKESMAS 11 ILIR

JL. SLAMET RIADY NO. 455 11 ILIR , KEC. ILIR TIMUR II

DR. H. EZRIN NOER

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

15

1500000000977

PUSKESMAS 23 ILIR

JL. DATUK M. AKIB NO. 100, KEC. BUKIT KECIL

DR. SALMAH HAMID

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1500000000965

PUSKESMAS 4 ULU

JL. WAHID HASYIM 4 ULU DARAT, KEC. SEBERANG ULU I

DR. H. NURHAYATI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

17

1500000000987

PUSKESMAS 5 ILIR

JL. BAMBANG UTOYO, KEC. ILIR TIMUR II

DR. PEMI WELRADO

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

5612245

542628


SM0480



84 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

18

1500000000966

PUSKESMAS 7 ULU

JL. K.H. AZHARI 7 ULU, KEC. SEBERANG ULU I

DR. RUSTINA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

19

1500000001013

PUSKESMAS ALANG-ALANG LEBAR

KEC. ALANG ALANG LEBAR

DR. HJ. SYARI MASYITAH

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

20

1500000000979

PUSKESMAS ARIODILLAH

JL. ARIODILLAH NO. 2102, KEC. ILIR TIMUR I

DR. HJ. MARTINA MUDJITABA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

21

1500000000983

PUSKESMAS BASUKI RAHMAT

JL. SERSAN SANI NO. 1350 RT. 18, KEC. KEMUNING

DR. RA. EMIRIA UMI K

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

22

1500000000989

PUSKESMAS BOOM BARU

JL. MAYOR MEMET SASTRAWIRYA NO. 29 LAWANG KIDUL, KEC. ILIR TIMUR II

DR. DIAN HAYATI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

23

1500000000998

PUSKESMAS BUKIT SANGKAL

JL. TANJUNG SARI II NO. 46 RT. 33, KEC. KALIDONI

DR. HILDA MARHAENI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

24

1500000000980

PUSKESMAS DEMPO

JL. KOLONEL ATMO NO. 17, KEC. ILIR TIMUR I

DR. HJ. MEIRI IRYANI, M.KES

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

25

1500000000960

PUSKESMAS GANDUS

JL. TPH. SOFYAN KENAWAS NO. 690, KEC. GANDUS

DR. APRIYANTI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

26

1500000001001

PUSKESMAS KALIDONI

JL. TALANG GADNG RT. 07 NO. 78 TALANG GADING, KEC. KALIDONI

DR. DOVI YUNIARTI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

27

1500000000973

PUSKESMAS KAMPUS

JL. GOLF BLOK G-6 KAMPUS, KEC. ILIR BARAT I

DR. YULIARNI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

28

1500000000969

PUSKESMAS KARYA JAYA

DS. KARYA JAYA DARAT, KEC. KERTAPATI

DR. DARLINA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

29

1500000000990

PUSKESMAS KENTEN

JL. MANGKUNEGARA NO. 1 KENTEN, KEC. ILIR TIMUR II

DR. HJ. AGUSTINI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

30

1500000000968

PUSKESMAS KERTAPATI

JL. KOMPLEK SEMEN BATURAJA, KEC. KERTAPATI

DR. ERINE DWINDA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

31

1500000000963

PUSKESMAS KRAMASAN

JL. ABIKUSNO COKRO SUYOSO LRG GOTONG ROYONG, KEC. KERTAPATI

DRG. ANDHIKA SITASARI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

32

1500000000959

PUSKESMAS MAKRAYU

JL. MAKRAYU 32 ILIR, KEC. ILIR BARAT II

DR. HJ. NOVIA DIANA ROZA, M.KES

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

33

1500000000978

PUSKESMAS MERDEKA

JL. MERDEKA NO. 66 PALEMBANG, KEC. BUKIT KECIL

DR. HJ. DESTY ARYANI, M.KES

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

34

1500000001003

PUSKESMAS MULTIWAHANA

JL. MITRA RAYA BLOK H NO. 4858, KEC. SAKO

DRG. KIKI AYU MARLINA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

35

1500000000970

PUSKESMAS NAGASWIDAK

JL. A. YANI LR GUMAI RT 22, 14 ULU, KEC. SEBERANG ULU II

DRG. BENCAS NAINGGOLAN

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

36

1500000000964

PUSKESMAS OPI

DS. 15 ULU, KEC. SEBERANG ULU I

DRG. M. ERWAN NAUPAL

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

37

1500000000976

PUSKESMAS PADANG SELASA

JL. PADANG SELASA BUKIT BESAR, KEC. ILIR BARAT I

DRG. LIZANNA FARIANTY Y

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

38

1500000000974

PUSKESMAS PAKJO

JL. INSPEKTUR MARZUKI NO. 2240, KEC. ILIR BARAT I

DRG. NINA AGUSTINA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

39

1500000000961

PUSKESMAS PEMBINA

JL. A. YANI NO. 62 SILABERANTI, KEC. SEBERANG ULU I

DR. ERFIANA UMAR, M.KES

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

40

1500000000972

PUSKESMAS PLAJU

JL. DI PANJAITAN PLAJU ULU, KEC. PLAJU

DR. HJ. RITA AGUSTINA, M.KES

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

41

1500000001012

PUSKESMAS PUNTIKAYU

JL. SRIJAYA KM 5.5, KEC. ALANG ALANG LEBAR

DR. NYAYU FAISAL

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

42

1500000000991

PUSKESMAS SABOKINGKING

JL. SABOKINGKING NO. 13 RT. 1, KEC. ILIR TIMUR II

DR. HJ. ARINA WARDHANI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

43

1500000001004

PUSKESMAS SAKO

JL. LEMATANG RAYA NO. 16 RT. 29 LEBONG GAJAH, KEC. SEMATANG BORANG

DR. HERAWATI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

44

1500000000997

PUSKESMAS SEI SELINCAH

JL. MAYOR ZEN SEI SELINCAH, KEC. KALIDONI

DR. HJ. SRI MARIAWATI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

45

1500000000984

PUSKESMAS SEKIP

JL. AMPHIBI NO. 812 RT.09 RW.03, KEC. KEMUNING

DR. HJ. MAHYUNIS MAHMOEDDIN

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

46

1500000001006

PUSKESMAS SOSIAL

JL. SOSIAL KOMPLEK PSBD "BUDI PERKASI" KM. 5, KEC. SUKARAMI

DR. MERIANCE

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

47

1500000001007

PUSKESMAS SUKARAME

JL. KEBUN BUNGA RT. 37 NO. 1 KM. 9, KEC. SUKARAMI

DRG. PURNAMAWATI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

48

1500000000975

PUSKESMAS SUNGAI BAUNG

JL. PERTIWI RT.10 DWIKORA II, KEC. ILIR BARAT I

DR. NURIN ERLYNDIA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

49

1500000001011

PUSKESMAS TALANG BETUTU

JL. TALANG BETUTU, KEC. SUKARAMI

DR. MSY MEIDIAWANI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

50

1500000000981

PUSKESMAS TALANG RATU

JL. TALANG RATU KM 5 ILIR D-IV, KEC. ILIR TIMUR I

DRG. INDRIATI

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

51

1500000000971

PUSKESMAS TAMAN BACAAN

JL. K.H. AZHARI TAMAN BACAAN, KEC. SEBERANG ULU II

DRG. ERMINDA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

52

1500000000183

RS MUHAMMADIYAH PALEMBANG

JL A. YANI RT.028 RW. 001 KELURAHAN 13 ULU KECAMATAN SEBRANG ULU II

513144

DR. H. YUDI FADILAH, SPPD, FINASIM

PER/03/012015

RS.TRAUMA CENTRE

14/01/2016

31/12/2016

53

1500000000183

RS MUHAMMADIYAH PALEMBANG

JL A. YANI RT.028 RW. 001 KELURAHAN 13 ULU KECAMATAN SEBRANG ULU II

513144

DR. H. YUDI FADILAH, SPPD, FINASIM

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

54

1400000000163

RS PELABUHAN PALEMBANG

JL MAYOR MEMET SASTRAWIRYA NO 01 BOOM BARU

712840

DR DEDY NUGROHO

PER/01/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2017

55

1400000000163

RS PELABUHAN PALEMBANG

JL MAYOR MEMET SASTRAWIRYA NO 01 BOOM BARU

712840

DR DEDY NUGROHO

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

56

1400000000165

RS PERTAMINA PLAJU PALEMBANG

JL PENGANTINGAN NO 1 KOMPERTA PLAJU

DR DODY ALAMSYAH SIREGAR

PER/15/042015

RS.TRAUMA CENTRE

29/04/2015

31/03/2016

57

1400000000200

RS TK II DR AK GANI

JL DR AK GANI NO 01

DR MADE WIRAYASA TUSAN

PER/21/062015

RS.TRAUMA CENTRE

20/06/2015

31/05/2016

58

1500000000597

RSIA SITI MIRZA

JL. DEMANG LEBAR DAUN (SAMPING BANK BCA DEMANG LEBAR DAUN PALEMBANG)

446272

PT. DWI JAYA SERASI

PER/12/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

59

1500000000686

RSIA YK MADIRA

JL. JENDRAL SUDIRMAN 1051 C-D-E

364954

YAYASAN YK MAIRA

PER/11/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

60

1500000000926

RSK DR RIVAI ABDULLAH PALEMBANG

JL. SUNGAI KUNDUR KELURAHAN MARIANA KECAMATAN BANYUASIN 1

KEMENKES

PER/20/052015

RS.TRAUMA CENTRE

01/04/2015

31/12/2016

61

1500000000300

RSUD KAYU AGUNG

JALA. MARZUKI ZAHRI NO.1037 CINTARAJA KAYUAGUNG

323889

RSUD KAYU AGUNG

PER/04/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

62

1500000000509

RSUD SEKAYU

JALAN KOLONEL WAHID UDIN LINGKUNGAN 1 KELURAHAN KAYUARA SEKAYU

321855

DR IRA

PER/09/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

63

1400000000167

RUMAH SAKIT BHAYANGKARA PALEMBANG

JL JEND SUDIRMAN KM 4,5 PALEMBANG

DR SYAMSUL BAHAR

PER/28/062015

RS.TRAUMA CENTRE

05/06/2015

31/05/2016

64

1500000000705

RUMAH SAKIT BUNDA PALEMBANG

JALAN DEMANG LEBAR DAUN NO. 70 PALEMBANG

YAYASAN BUNDA

PER/07/042015

RS.TRAUMA CENTRE

01/04/2015

30/04/2016

65

1500000000928

RUMAH SAKIT KHUSUS PARU PROVINSI SUMATERA SELATAN

JL. MERDEKA NOMOR 10 PALEMBANG

PER/13/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

66

1400000000236

RUMAH SAKIT MYRIA PALEMBANG

JL KOL H BURLIAN NO 228 PALEMBANG

67

1500000001101

UPTD BLK INDUSTRI DISNAKERTRANS

68

1500000001101

UPTD BLK INDUSTRI DISNAKERTRANS

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

IKS TELEPON

PIMPINAN NO IKS DR F X INDRA SETIADI MARS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/24/062015

RS.TRAUMA CENTRE

11/06/2015

31/05/2016

JL. RESIDEN H AMALUDDIN SAKO KENTEN

PER/02/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

JL. RESIDEN H AMALUDDIN SAKO KENTEN

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

G01- KANTOR CABANG BENGKULU

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000414

KLINIK BETESDA

JL. LINTAS PAGAR ALAM DESA PERMU IMIGRASI

ROSMAWATI PURBA

PER/08/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2017

2

1500000000415

KLINIK MEDISTRA

JL. S PARMAN RT.01 RW.01 KEL. TANAH PATAH

ICHSANA PRANATAWATI

PER/09/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2017

3

1500000000650

KLINIK PRATAMA GUNUNG BUNGKUK MEDIKA

JALAN ROKAN KIRI NO.1 KEL. PADANG HARAOAN KEC. GADING CEMPAKA

PEMERINTAH PROVINSI BENGKULU

PER/16/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

4

1500000000862

PKM KEMBANG SERI

JALAN RAYA BENGKULU-CURUP KM. 14 BENGKULU TENGAH

PEMKAB BENGKULU TENGAH

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

5

1500000000298

RS BHAYANGKARA TK III BENGKULU

JL. VETERAN NO.02 BENGKULU

341086

POLRI

PER/02/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2017

6

1500000000298

RS BHAYANGKARA TK III BENGKULU

JL. VETERAN NO.02 BENGKULU

341086

POLRI

PER/02/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2017

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

1500000000982

RS TK IV 02.07.01 ZAINUL ARIFIN

JL. ZAINAL ARIFIN GADING CEMPAKA

21048

KODAM II SRIWIJAYA

PER/11/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

8

1500000000982

RS TK IV 02.07.01 ZAINUL ARIFIN

JL. ZAINAL ARIFIN GADING CEMPAKA

21048

KODAM II SRIWIJAYA

PER/11/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

9

1500000001315

RSUD ARGA MAKMUR

JALAN SITI KHADIJAH NO.08 ARGA MAKAMUR

521118

DR. JASMEN SILITONGA M.KES SPKK

PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

10

1500000000945

RSUD BENGKULU TENGAH

JL. RAYA BENGKULU-KEPAHIANG KM.34,5 BAJAK 1

75683474

PEMKAB BENGKULU TENGAH

PER/19/05/05201 5

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

11

1500000000468

RSUD DR. M YUNUS

JL BHAYANGKARA BENGKULU

52004

DR. H. SYAFRIADI

PER/02/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

12

1500000000533

RSUD MUKOMUKO

JALAN DANAU NIBUNG DESA KOTA PRAJA

71148

PEMERINTAH KABUPATEN MUKOMUKO

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2018

KANTOR CABANG

NO

KODE PROVIDER

:

G02- KANTOR CABANG PANGKAL PINANG

NAMA PROVIDER

ALAMAT

1

1500000000601

BIDDOKKES POLDA KEP. BANGKA BELITUNG

JL MERDEKA NO 12 PANGKALPINANG

2

1500000001511

BLK PROVINSI KEPULAUAN BANGKA BELITUNG

AIR ITAM, KOMPLEK PERKANTORAN GUBERNUR PROVINSI KEPULAUAN BANGKA BELITUNG

3

1400000000730

BPRB MEDIKA STANNIA

BELINYU

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DISNAKER PROVINSI KEPULAUAN BANGKA BELITUNG

PER/021/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

YAYASAN BAKTI TIMAH

PER/001/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000000133

KLINIK BAKTI TIMAH PARIT TIGA

JL. RAYA PARIT TIGA

351143

YAYASAN BAKTI TIMAH

PER/002/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

5

1500000000130

KLINIK BAKTI TIMAH TANJUNGPANDAN

JL. MELATI NO. 23 TANJUNGPANDAN

21865

YAYASAN BAKTI TIMAH

PER/002/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

6

1500000000131

KLINIK BAKTI TIMAH TOBOALI

JL. JEND. SUDIRMAN 227 TOBOALI

41771

YAYASAN BAKTI TIMAH

PER/002/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

7

1500000001400

KLINIK INTAN MEDIKA

JL GIOK NO 77 KEL BUKIT INTAN KEC BUKIT INTAN PANGKALPINANG

434099

DR. HENDRI JAN

PER/019/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1500000001509

KLINIK PRATAMA BAKTI TIMAH

YAYASAN BAKTI TIMAH

PER/022/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1500000001452

KLINIK UTAMA TANJUNG PANDAN

TANJUNG PANDAN

DR YUSTINUS

PER/023/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

10

1500000000612

PUSKESMAS BAKAM

JL. RAYA PANGKAL PINANG - MENTOK KM 38 DESA BAKAM KEC BAKAM

H. SOFIANDI, SKM, M. SI

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1500000000609

PUSKESMAS BATU RUSA

JALAN RAYA BATU RUSA KAB BANGKA


PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

12

1500000000617

PUSKESMAS BELINYU

JL DEPATI BARIN BELINYU BANGKA


PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

13

1500000001548

PUSKESMAS BENTENG

JL BATU BELUBANG DUSUN BENTENG KEC PANGKALAN BARU

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

14

1500000000616

PUSKESMAS GUNUNG MUDA

BELINYU

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

15

1500000001501

PUSKESMAS JEBUS

JLN. KAMPAK NO.188 NO.188 DESA JEBUS, KEC. JEBUS

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I



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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

16

1500000001499

PUSKESMAS KELAPA

JLN. RAYA KELAPA TIMUR, KEL. KELAPA, KEC. KELAPA

17

1500000000607

PUSKESMAS KENANGA

SUNGAILIAT

18

1500000001549

PUSKESMAS KOBA

19

1500000001498

20

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

JL POS KOBA KEL KOBA KEC KOBA

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PUSKESMAS KUNDI

JLN. BARU, DUSUN III, DESA KUNDI, KEC. SP.TERITIP

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1500000001547

PUSKESMAS LAMPUR

JL RAYA LAMPUR KEC SUNGAI SELAN

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

21

1500000001550

PUSKESMAS LUBUK

JL RAYA LUBUK BESAR DS LUBUK BESAR KEC KOBA

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

22

1500000001496

PUSKESMAS MUNTOK

JLN. BASUKI RAHMAT, KEL. SUNGAI DAENG, KEC. MUNTOK

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

23

1500000001544

PUSKESMAS NAMANG

JL RAYA NAMANG DUSUN KOBA PANGKALAN BARU

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

24

1500000001543

PUSKESMAS PANGKALAN BARU

JL RAYA KOBA DUSUN BELULUK PANGKALAN BARU

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

25

1500000000614

PUSKESMAS PEMALI

PEMALI - BANGKA


PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

26

1500000000611

PUSKESMAS PENAGAN

MENDO BARAT


PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

27

1500000000610

PUSKESMAS PETALING

JLN RAYA PANGKAL PINANG MENTOK KM DESA PETALING KEC MENDO BARAT KAB BANGKA


PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I



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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

JL. TAMBANG KERING DS. SEKAR BIRU, KEC. JEBUS

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PUSKESMAS SIMPANG KATIS

JL RAYA SUNGAI SELAN DUSUN SIMPANG KATIS KEC SIMPANG KATIS

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1500000001497

PUSKESMAS SIMPANG TERITIP

JLN. POROS MUNTOK- PANGKALPINANG, KEC. SP. TERITIP

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

30/05/2016

34

1500000000608

PUSKESMAS SINAR BARU

SUNGAILIAT

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

35

1500000001546

PUSKESMAS SUNGAI SELAN

JL BATIN TIKAL DUSUN SUNGAI SELAN KEC SUNGAI SELAN

PER/024/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

36

1500000000606

PUSKESMAS SUNGAILIAT

JL JEND SUDIRMAN SUNGALIAT BANGKA

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

37

1500000001500

PUSKESMAS TEMPILANG

JL. PANGLIMA ANGIN NO. 20 DS. TEMPILANG, KEC. TEMPILANG

PER/020/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

38

1400000000112

RS ALMAH

JL. JEND. SUDIRMAN DESA BULUH TUMBANG DUSUN PERAWAS II RT 3 RW 2 TANJUNG PANDAN

PER/015/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

39

1400000000098

RS ARSANI

JL RAYA KENANGA SUNGAILIAT

PER/05/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

28

1500000000613

PUSKESMAS PUDING BESAR

PUDING BESAR

29

1500000001502

PUSKESMAS PUPUT

JL. PASAR PARIT III DS. PUPUT, KEC. JEBUS

30

1500000000615

PUSKESMAS RIAU SILIP

RIAU SILIP

31

1500000001503

PUSKESMAS SEKAR BIRU

32

1500000001545

33

MA11222I





HIDAYAT ARSANI

4297825


SM0480



93 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

40

1400000000097

RS BAKTI TIMAH

JL JEND SUDIRMAN KEC TAMAN SARI PANGKALPINANG

41

1500000000132

RS BAKTI TIMAH MUNTOK

JL. RAYA TIMAH KOMPLEK PUSMET MUNTOK

42

1400000000091

RS BHAKTI WARA

JL. SUNGAI SELAN KM.4 PANGKALPINANG

43

1500000000602

RSUD BELITUNG TIMUR

44

1400000000089

45

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

YAYASAN BAKTI TIMAH

PER/012/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

21008

YAYASAN BAKTI TIMAH

PER/002/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

422605

YAYASAM TUNAS KARYA

PER/017/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

JL RAYA GANTUNG DS PADANG MANGGAR

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

RSUD DEPATI HAMZAH PANGKAL PINANG

JL MAYOR SYAFRIE RACHMAN PANGKAL PINANG

PER/014/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

1400000000729

RUMAH SAKIT MEDIKA STANNIA

JL. JEND. SUDIRMAN NO. 03 SUNGAILIAT

YAYASAN BAKTI TIMAH

PER/001/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

46

1500000000619

SPGD (SISTEM PENANGGULANGAN GAWAT DARURAT)

SUNGAILIAT


PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

47

1500000001398

SUN CLINIC

EL JOHN JL SOEKARNO HATTA NO 208 PANGKALPINANG

PER/018/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1500000001268

MA11222I

:

95837

4297888

G03- KANTOR CABANG MUARA ENIM

NAMA PROVIDER

BALAI LATIHAN KERJA KAB.MUARA ENIM

ALAMAT

JALAN PETROSIA III MUARA ENIM

KODE POS

IKS TELEPON

PIMPINAN NO IKS KAB MUARA ENIM

PER/41/062015


TIPE IKS RS.TRAUMA CENTRE

AWAL IKS 08/05/2015


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1500000001202

BALAI LATIHAN KERJA KOTA PRABUMULIH

JL JEND SUDIRMAN KM 35

320618

KOTA PRABUMULIH

PER/42/062015

RS.TRAUMA CENTRE

08/06/2015

07/06/2016

3

1500000001075

KLINIK 3F MEDIKA

JL PUNCAK II NO 748 RT 03/03 GUMAWANG BELITANG

451299

DR HJ TRIKANDIANI

PER/37/052015

RS.TRAUMA CENTRE

25/05/2015

24/05/2016

4

1500000000763

KLINIK FADHILAH

PT TEL DI DESA NIRU KEC RAMBANG DANGKU

24102380

RS FADHILAH

PER/28/042014

RS.TRAUMA CENTRE

05/05/2015

04/05/2016

5

1500000000764

KLINIK FCM 24 JAM

JL PADAT KARYA KELURAHAN GUNUNG IBUL

68044521

DR TRISNAYANTI

PER/29/042015

RS.TRAUMA CENTRE

05/05/2015

04/05/2016

6

1500000001232

PKM PAJAR BULAN

DS PAJAR BULAN , KEC SEMENDO DARAT ULU KAB MUARA ENIM

69870030

MUARA ENIM

PER/44/062015

RS.TRAUMA CENTRE

08/06/2015

07/06/2016

7

1500000001505

PUSKESMAS GELUMBANG KAB. MUARA ENIM

DS GELUMBANG KEC. GELUMBANG

73610770

KAB MUARA ENIM

PER/46/062015

RS.TRAUMA CENTRE

15/06/2015

14/06/2016

8

1500000001231

PUSKESMAS TANJUNG RAYA

DS TANJUNG RAYA KEC SEMENDO DARAT TENGAH

73720427

MUARA ENIM

PER/45/062015

RS.TRAUMA CENTRE

08/06/2015

07/06/2016

9

1500000000498

RS AR BUNDA LUBUKLINGGAU

JL GARUDA NO 245 RT 3 KEL BANDUNG KIRI KEC LUBUKLINGGAU BARAT I

324963

DR SARAH AINAR RAHMAN

PER/14/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

10

1500000000599

RS AR BUNDA PRABUMULIH

JL ANGKATAN 45 NO 525 KELURAHAN GUNUNG IBUL

322954

DR H ALIP YANSON

PER/19/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

11

1500000001113

RS BUKIT ASAM MEDIKA

JL RAYA BUKIT ASAM NO 118 TANJUNG ENIM

PT BUKIT ASAM

PER/40/052015

RS.TRAUMA CENTRE

25/05/2015

24/05/2016

12

1500000000639

RS DR SOBIRIN

JL YOS SUDARSO NO 13 LUBUK LINGGAU

321013

KAB.MUSI RAWAS

PER/16/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

13

1500000000519

RS FADHILAH

JL JEND SUDIRMAN NO 01 PRABUMULIH

3300032

DR TRISNAYANTI

PER/18/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

14

1500000000750

RS PANTI BHAKTININGSIH CHARITAS BELITANG

JL TEGAL REJO BK X BELITANG

824244

YAYASAN BHAKTININGSIH

PER/31/052015

RS.TRAUMA CENTRE

11/05/2015

10/05/2016

15

1400000000192

RS PERTAMINA PRABUMULIH

JL. KESEHATAN NO. 100 KOMPERTA PRABUMULIH

382742

PT. PERTAMINA BINA MEDIKA

PER/21/04/2015

RS.TRAUMA CENTRE

01/05/2015

12/04/2016

16

1500000000912

RS RUMKIT TK IV DR NOESMIR BATURAJA

JL DR MOH HATTA NO 64 BATURAJA

320123

OKU

PER/30/052015

RS.TRAUMA CENTRE

11/05/2015

10/05/2016

17

1500000000535

RS SANTO ANTONIO

JL KOMISARIS UMAR NO 33, BATURAJA 32121

320395

YAYASAN SANTO GEORGIUS

PER/35/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

18

1500000001082

RS TNI AD TK/IV.02.07.02 LAHAT

JL MAYOR RUSLAN I LAHAT

TNI AD LAHAT

PER/35/052015

RS.TRAUMA CENTRE

18/05/2015

17/05/2016

19

1500000001073

RSUD BASEMAH KOTA PAGAR ALAM

JL AIS NASUTION NO.03 PAGAR ALAM

KAB PAGAR ALAM

PER/38/052015

RS.TRAUMA CENTRE

25/05/2015

24/05/2016

20

1500000000760

RSUD DR H IBNU SUTOWO

JL MOH HATTA NO 1 BATURAJA

320298

KAB OKU

PER/33/052015

RS.TRAUMA CENTRE

11/05/2015

10/05/2016

21

1500000000645

RSUD LAHAT

JL LETJEN HARUN SOHAR I NO 28 LAHAT

21785

LAHAT

PER/27/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

22

1500000000536

RSUD MARTAPURA

JL LETNAN MUCHTAR NO 185 TEBAT SARI

481004

PEMDA OKU TIMUR

PER/22/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

23

1500000000738

RSUD MUARA DUA

JL RANAU DESA SUKAJAYA KEC BUAI RAWAN

67418413

OKU TIMUR

PER/20/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

24

1500000001074

RSUD MUARA RUPIT

JL KESEHATAN NO 1 DESA LAWANG AGUNG KEC RUPIT

MUSI RAWAS UTARA

PER/39/052015

RS.TRAUMA CENTRE

25/05/2015

24/05/2016

25

1500000000544

RSUD OKU TIMUR

JL RAYA BELITANG RASUAN NO 1 DESA TULUS AYU KEC BELITANG MANDAGA RAYA

KAB.OKU TIMUR

PER/23/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

MA11222I

450319


SM0480



96 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

26

1500000000640

RSUD PRABUMULIH

JL LINGKAR KEL GUNUNG IBUL PRABUMULIH TIMUR

7001085

KOTA BRABUMULIH

PER/26/042016

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

27

1500000000692

RSUD SITI AISYAH

JL LAPTER SILAMPARI KELURAHAN AIR KUTI

452776

LUBUK LINGGAU

PER/17/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

28

1500000000691

RSUD TALANG UBI

JL TAMAN SISWA KELURAHAN PASAR BHAYANGKARA, KECAMATAN TALANG UBI

390487

PENUKAL ABAB LEMATANG ILIR

PER/24/042015

RS.TRAUMA CENTRE

13/04/2015

12/04/2016

29

1500000000856

RSUD TEBING TINGGI

JL TEBING BENTENG NO.1 KELURAHAN KUPANG KEC TEBING TINGGI

21047

EMPAT LAWANG

PER/34/052015

RS.TRAUMA CENTRE

18/05/2015

17/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

H00- KANTOR CABANG BANDAR LAMPUNG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000274

BP DARAPETAK

JL. RAYA BRANTI DESA BUMI SARI KEC. NATAR

082177114 63

DR ELVIRA IRIANTY

PER/15/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

2

1400000000113

KLINIK KEDATON MEDICAL CENTER

JL. ZAINAL ABIDIN PAGAR ALAM NO 77/79 GEDUNG MENENG

089623631 169

DR. ERVAN BUDIAWAN

PER/13/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

3

1400000000115

KLINIK KELUARGA PANJANG MEDIKA

JALAN TELUK AMBON NO 14 KEL. PIDADA PANJANG

081279111 659

DR AILA KARYUS

PER/16/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

4

1400000000503

KLINIK KOSASIH AMANAH

JL. IKAN KEMBUNG NO. 70 A TELUK BETUNG BANDAR LAMPUNG

35223

7175938

DR.S.TRI.HERLIANTO,SH, MH,MM,MKES

PER/25/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

5

1400000000500

KLINIK KOSASIH KEMILING

JL. TEUKU CIK DITIRO BLOK E NO. 4 KEMILING BANDAR LAMPUNG

35158

3540424


PER/22/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

MA11222I


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

6

1400000000504

KLINIK KOSASIH PALAPA

JL. CUT NYAK DIEN NO. 62 PALAPA BANDAR LAMPUNG

7

1400000000507

KLINIK KOSASIH PANJANG

8

1400000000498

9

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7140218


PER/26/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

JL. TANJUNG PURA II NO. 50 PANJANG UTARA BANDAR LAMPUNG

9761738


PER/28/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

KLINIK KOSASIH SUMBER WARAS

JL. RAYA GADING REJO NO. 221 GADING REJO

7910645


PER/20/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

1400000000508

KLINIK KOSASIH TANJUNGAN

JL. LINTAS SUMATERA SIMPANG KATES TANJUNG AGUNG LAMPUNG SELATAN

7773665


PER/29/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

10

1400000000501

KLINIK KOSASIH TELUK

JL. IKAN SALEM NO. 05 TELUK BETUNG BANDAR LAMPUNG

7641529


PER/23/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

11

1400000000502

KLINIK KOSASIH TIRTAYASA

JL. PANGERAN TIRTAYASA NO. 181 SUKABUMI BANDAR LAMPUNG

7167635


PER/24/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

12

1400000000114

KLINIK LEMATANG MEDICAL CENTER

JL. SUTAMI KM. 11 NO. 135 LEMATANG TANJUNG BINTANG

089631062 444

DR AGUS KELANA BENNI KURNIAWAN

PER/14/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

13

1400000000499

KLINIK MITRA KOSASIH

JL. MS. BATUBARA NO. 70 KUPANG TEBA TELUK BETUNG BANDAR LAMPUNG

7327768


PER/21/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

14

1400000000497

KLINIK RAWAT INAP KOSASIH RAJABASA

JL. KAPTEN ABDUL HAQ NO 9/31 RAJABASA

7511491


PER/19/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

15

1400000000505

KLINIK RAWAT INAP KOSASIH TUGU

JL. KAPTEN HAYAM WURUK NO. 20 TANJUNG KARANG TIMUR

7365397


PER/27/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

16

1400000000496

KLINIK RAWAT INAP KOSASIH URIP

JL URIP SUMOHARJO NO 176 KEDATON

3526413


PER/18/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

17

1500000000181

RS GLADISH MEDICAL CENTER

JL. RAYA AHMAD YANI NO.36 RT 01 RW 01 DESA TAMAN SARI KEC. GEDONG TATAAN KAB. PESAWARAN

CV GLADISH MEDICAL CENTER

PER/04/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

MA11222I

35116


SM0480



98 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

18

1500000000700

RS IMANUEL WAY HALIM

JL. SOEKARNO HATTA KEL. WAY DADI KEC. SUKARAME

704900

YAYASAN RUMAH SAKIT BAPTIS INDONESIA

PER/12/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

19

1500000000401

RS MITRA HUSADA

JL. JEND. A. YANI NO. 14 PRINGSEWU

23792

PT MITRA HUSADA BERSAMA

PER/11/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

20

1500000000253

RS MUHAMMADIYAH METRO

JL. SOEKARNO HATTA NO. 42 MULYOJATI 16 B KEC. METRO BARAT KOTA METRO

7008000

PERSYARIKATAN MUHAMMADIYAH

PER/09/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

21

1500000000209

RS NATAR MEDIKA

JL. RAYA NATAR NOMOR 4 MUARA PUTIH

92521

YAYASAN ABDI KARYA

PER/07/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

22

1500000000218

RS TINGKAT IV 02.07.04 (RS DKT) BANDAR LAMPUNG

JL. KAPT. A RIVAI 7 PENENGAHAN TANJUNG KARANG PUSAT

770430

PER/08/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

23

1400000000116

RS URIP SUMOHARJO

JL URIP SUMOHARJO NO 200 SUKARAME

771322

PT GUNUNG SULAH MEDIKA

PER/10/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

24

1500000000115

RS WISMA RINI

JL. WISMA RINI NO. 01 PRINGSEWU

21582

YAYASAN BUDI SETIA BHAKTI

PER/01/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

25

1500000000165

RSUD DR. H. ABDUL MOELOEK PROVINSI LAMPUNG

JALAN DR. RIVAI NOMOR 06 PENENGAHAN

703312

PROVINSI LAMPUNG

PER/05/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

26

1500000000165

RSUD DR. H. ABDUL MOELOEK PROVINSI LAMPUNG

JALAN DR. RIVAI NOMOR 06 PENENGAHAN

703312

PROVINSI LAMPUNG

PER/05/012015

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

27

1400000000471

RSUD DR. H. BOB BAZAR, SKM

JALAN LETTU ROHANI NOMOR 14B KALIANDA

322160

PER/30/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

28

1500000000134

RSUD PESAWARAN

JL. RAYA KEDONDONG DESA WAY LAYAP KEC. GEDONG TATAAN

KABUPATEN PESAWARAN

PER/03/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

29

1500000000134

RSUD PESAWARAN

JL. RAYA KEDONDONG DESA WAY LAYAP KEC. GEDONG TATAAN

KABUPATEN PESAWARAN

PER/03/012015

RS.TRAUMA CENTRE

01/02/2016

31/01/2016

MA11222I


SM0480



99 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

30

KODE PROVIDER

UPTD BALAI LATIHAN KERJA BANDAR LAMPUNG

1500000000427

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

:

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS DINAS TENAGA KERJA DAN TRANSMIGRASI PROVINSI LAMPUNG

JL. PAGAR ALAM NOMOR 127 BANDAR LAMPUNG

PER/06/022015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/03/2015


H01- KANTOR CABANG LAMPUNG TENGAH

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000710

BP. ALAYA MEDIKA

JALAN JENDRAL SUDIRMAN NO. 407 KOTABUMI

DR. HJ. MAYA METISSA

PER/009/042015

RS.TRAUMA CENTRE

24/04/2015

23/04/2016

2

1500000001188

PUSKESMAS BANDAR AGUNG

BANDAR AGUNG, KEC. TERUSAN NUNYAI

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

3

1500000001192

PUSKESMAS BANDAR JAYA

JL. A.YANI NO.33 BANDAR JAYA, KEC. TERBANGGI BESAR

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

4

1500000001168

PUSKESMAS BANGUNREJO

DS. BANGUNREJO, KEC. BANGUNREJO

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

5

1500000001181

PUSKESMAS BINA KARYA UTAMA

BUMI NABUNG, KEC. BUMI NABUNG

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

6

1500000001182

PUSKESMAS BUMI NABUNG

BUMI NABUNG, KEC. BUMI NABUNG

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

7

1500000001189

PUSKESMAS CANDI REJO

JL. RAYA LINTAS SUMATERA, KEC. WAY PANGUBUAN

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

8

1500000001179

PUSKESMAS GAYA BARU LIMA

GAYA BARU V, KEC. BANDAR SURABAYA

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

MA11222I


SM0480



100 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

9

1500000001164

PUSKESMAS GEDUNG SARI

GEDUNG SARI, KEC. ANAK RATU AJI

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

10

1500000001171

PUSKESMAS GUNUNG SUGIH

DS. GUNUNG SUGIH, KEC. GUNUNG SUGIH

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

11

1500000001163

PUSKESMAS HAJI PEMANGGILAN

DS. HAJI PEMANGGILAN, KEC. ANAK TUHA

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

12

1500000001186

PUSKESMAS JATI DATAR

JATI DATAR, KEC. BANDAR MATARAM

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

13

1500000001165

PUSKESMAS KALIREJO

KALIREJO, KEC. KALIREJO

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

14

1500000001156

PUSKESMAS KARANG ANYAR

DS. KARANG ANYAR, KEC. SELAGAI LINGGA

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

15

1500000001173

PUSKESMAS KESUMADADI

DS. KASUMADADI, KEC. BEKRI

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

16

1500000001196

PUSKESMAS KOTA GAJAH

JL. RAYA GUNUNG SUGIH, KEC. KOTA GAJAH

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

17

1500000001118

PUSKESMAS PADANG RATU

HAYUNGAN RATU, KEC. PADANG RATU

DR. LINDAWATY

PER/012/052015

RS.TRAUMA CENTRE

29/05/2015

28/04/2016

18

1500000001157

PUSKESMAS PAYUNG REJO

DS. PAYUNGREJO, KEC. PUBIAN

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

19

1500000001166

PUSKESMAS PONCOWARNO

DS. PONCOWARNO, KEC. KALIREJO

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

20

1500000001191

PUSKESMAS PONCOWATI

JL. A.YANI NO.1 PONCOWATI, KEC. TERBANGGI BESAR

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

21

1500000001198

PUSKESMAS PUJO KERTO

JL. RAYA GOTONG ROYONG, KEC. TRIMURJO

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

22

1500000001197

PUSKESMAS PUNGGUR

TANGGULANGIN, KEC. PUNGGUR

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

23

1500000001193

PUSKESMAS RAMA INDRA

RAMA INDRA, KEC. SEPUTIH RAMAN

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

24

1500000001183

PUSKESMAS RUMBIA

RESTU BARU, KEC. RUMBIA

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

25

1500000001162

PUSKESMAS SEGALA MIDER

JL PRAMUKA KAMPUNG SEGALA MIDER KEC PUBIAN

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

26

1500000001167

PUSKESMAS SENDANG AGUNG

DS. SENDANG AGUNG, KEC. SENDANG AGUNG

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

27

1500000001185

PUSKESMAS SEPUTIH BANYAK

DS. SEPUTIH BANYAK, KEC. SEPUTIH BANYAK

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

28

1500000001187

PUSKESMAS SEPUTIH MATARAM

REJOSARI, KEC. SEPUTIH MATARAM

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

29

1500000001194

PUSKESMAS SEPUTIH RAMAN

JL. RAYA SEPUTIH RAMAN, KEC. SEPUTIH RAMAN

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

30

1500000001180

PUSKESMAS SEPUTIH SURABAYA

SEPUTIH SURABAYA, KEC. SEPUTIH SURABAYA

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

31

1500000001199

PUSKESMAS SIMBAR WARINGIN

DS. SIMBAR WARINGIN, KEC. TRIMURJO

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

32

1500000001190

PUSKESMAS SIMPANG AGUNG

DS. SIMPANG AGUNG, KEC. SEPUTIH AGUNG

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

33

1500000001195

PUSKESMAS SRI TEJO KENCONO

SRITEJO KENCONO, KEC. KOTA GAJAH

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

34

1500000001176

PUSKESMAS SRI WIJAYA MATARAM

JATI DATAR, KEC. BANDAR MATARAM

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

35

1500000001170

PUSKESMAS SUKA NEGARA

SUKA NEGARA, KEC. BANGUNREJO

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

36

1500000001184

PUSKESMAS SUKO BINANGUN

JL. MERDEKA NO.1, KEC. WAY SEPUTIH

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

37

1500000001155

PUSKESMAS SURABAYA

DS. SURABAYA, KEC. PADANG RATU

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

38

1500000001172

PUSKESMAS TERBANGGI SUBING

JL. LINTAS SUMATERA,TERBANGGI SUBING, KEC. GUNUNG SUGIH

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

39

1500000001200

PUSKESMAS WATES

JL. RAYA LINTAS SUMATERA, KEC. BUMI RATU NUBAN

DR. LINDAWATY

PER / 012 / 052015

RS.TRAUMA CENTRE

29/05/2015

28/05/2016

40

1500000000357

RS BLK METRO

JALAN DEWI SARTIKA NO. 90 BANJAR SARI METRO UTARA

TRI RETNO PALUPI, SH

PER/005/032015

RS.TRAUMA CENTRE

05/03/2015

04/03/2016

41

1500000000651

RS BLK WAY ABUNG

JALAN TATA KARYA WAY ABUNG I

SUNARTO, SE

PER/010/042015

RS.TRAUMA CENTRE

27/04/2015

26/04/2016

42

1500000000319

RS HARAPAN BUNDA

JL. LINTAS SUMATERA NO. 30 SEPUTIH JAYA, GUNUNG SUGIH

DR. WIDYA SISTHA PRIMA, MARS

PER/007/032015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

43

1500000000318

RS ISLAM ASY-SYIFAA

JL. LINTAS SUMATRA KM 65 BANDAR JAYA

DR. JOSI HARNOS

PER/006/032015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

44

1400000000202

RSD MAYJEN. HM. RYACUDU

JL. JENDERAL SUDIRMAN NO. 2 KEC. KOTABUMI SELATAN

DR. HJ. MAYA METISSA

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

26766


SM0480



103 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

45

1500000000450

RSU HANDAYANI

JL. SOEKARNO HATTA NO. 94 TANJUNG HARAPAN KEC. KOTABUMI SELATAN

328399

DR. H. DJAUHARI THALIB, M.KES

PER/008/032015

RS.TRAUMA CENTRE

30/03/2015

29/03/2016

46

1400000000185

RSUD DEMANG SEPULAU RAYA

JALAN RAYA LINTAS SUMATERA KAMPUNG TERBANGGI AGUNG KEC. GUNUNG SUGIH

529898

DRG. ISMUDIJANTO

PER/014/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

47

1400000000308

RSUD MENGGALA

JL. MEGOW PAK NO. 08 MENGGALA

21131

DR. FEBY LEVARINA, SP.PK, M.KES

PER/015/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

J00- KANTOR CABANG JAKARTA SALEMBA

NAMA PROVIDER

ALAMAT

1

1500000001278

KLINIK PERTAMEDIKA

JL. PERWIRA NO.2-4 KEL. GAMBIR KEC. GAMBIR JAKARTA PUSAT

2

1500000001784

KLINIK PERTAMEDIKA DELI

JL AHMAD YANI NO 2, KEL UTAN KAYU

3

1500000001785

KLINIK PERTAMEDIKA MEDAN SATRIA

4

1500000001787

5

6

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/28/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

10110

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

KOMPLEKS PERTAMINA MEDAN SATRIA, JL ARUN IX NO 2

13110

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

KLINIK PERTAMEDIKA MEDICAL CENTRE SINABUNG

JL SINABUNG II NO 32 F

12110

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1500000001789

KLINIK PERTAMEDIKA MERDEKA TIMUR

JL MERDEKA TIMUR NO 12 JAKARTA PUSAT

10110

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1500000001788

KLINIK PERTAMEDIKA PATRA JASA

GD PATRA LT 1 RUANG 1E JL JEND GATOT SUBROTO KAV 32-34

12110

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I

DR NENY HERAWATI


SM0480



104 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

1500000001786

KLINIK PERTAMEDIKA RAWAMANGUN

JL MUNDU RAYA NO 1 RT/RW 12/04 PULO GADUNG

13110

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

8

1500000001790

KLINIK PERTAMEDIKA TUGU

JL HR RASUNA SAID KAV 8-9, KARET , SETIABUDI

12120

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

9

1500000001783

KLINIK PERTAMEDIKA YOS SUDARSO

JL YOS SUDARSO NO 34 ,TANJUNG PRIOK

14110

PER/47/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

10

1400000000304

KLINIK SUMBER SEHAT

JL. PERCETAKAN NEGARA 2 BLOK J NO. 1415, KELURAHAN JOHAR BARU

PER/53/082015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

11

1500000000951

PUSAT PELATIHAN KERJA DAERAH JAKARTA PUSAT

JALAN KARET PASAR BARU V NO 23 BENDUNGAN HILIR JAKARTA PUSAT

PER/30/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

12

1500000000993

PUSKESMAS KECAMATAN CEMPAKA PUTIH

JL CEMPAKA PUTIH BARAT XIX NO 2 RT 07/07

PER/36/062015

RS.TRAUMA CENTRE

01/01/2015

31/05/2016

13

1500000001821

PUSKESMAS KECAMATAN SENEN

JL KRAMAT VII NO 31 KEL KENARI

10110

PER/46/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

14

1500000001826

PUSKESMAS KELURAHAN BUNGUR

JL BUNGUR BESAR IX NO 20 RT 014/01

10110

PER/46/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

15

1500000001002

PUSKESMAS KELURAHAN CEMPAKA PUTIH BARAT II

JL CEMPAKA PUTIH BARAT 2D NO 10A

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1500000001823

PUSKESMAS KELURAHAN KENARI

JL JAMRUD NO 22 RT 008/02

10110

PER/46/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

17

1500000001822

PUSKESMAS KELURAHAN KRAMAT

JL KRAMAT SENTIONG I/33, RT 010/07

10110

PER/46/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

18

1500000001825

PUSKESMAS KELURAHAN KWITANG

JL KWITANG RAYA 1 C NO.27 RT 006/04

10110

PER/46/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I

4240700

DR EDI SETIAWAN


SM0480



105 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

19

1500000001824

PUSKESMAS KELURAHAN PASEBAN

JL KRAMAT SAWAH VII NO 7

20

1500000001005

PUSKESMAS KELURAHAN RAWASARI

21

1400000000198

22

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/46/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

JL PRAMUKA SARI 1 RT 01/08, RAWASARI, JAKARTA PUSAT

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

RS ISLAM JAKARTA CEMPAKA PUTIH

JL CEMPAKA PUTIH TENGAH I/1

PER/48/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1500000000328

RS MH THAMRIN SALEMBA

JALAN SALEMBA TENGAH NO 24 -28 JAKARTA PUSAT

PER/16/032015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

23

1400000000298

RS PERTAMINA JAYA

JL.JEND.ACHMAD YANI NO 2 CEMPAKA PUTIH

4211911

PER/51/082015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

24

1400000000298

RS PERTAMINA JAYA

JL.JEND.ACHMAD YANI NO 2 CEMPAKA PUTIH

4211911

PER/01/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

25

1500000000594

RS PREMIER JATINEGARA

JALAN RAYA JATINEGARA TIMUR NO.85-87 JAKARTA

PER/03/032015

RS.TRAUMA CENTRE

23/03/2015

23/03/2016

26

1400000000658

RS RIDWAN MAUREKSA

PER/62/122015

RS.TRAUMA CENTRE

01/12/2015

30/11/2016

27

1400000000351

RSIA EVASARI

JL. RAWAMANGUN NO. 27 PRAMUKA JAKARTA PUSAT 10570

4202851

PER/02/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

28

1400000000351

RSIA EVASARI

JL. RAWAMANGUN NO. 27 PRAMUKA JAKARTA PUSAT 10570

4202851

PER/52/082015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

KANTOR CABANG

MA11222I

:

10110

DR MIRA ROZIATI DACHLAN

DR.SRI WURYATI HANDAYANI

J02- KANTOR CABANG JAKARTA GROGOL


SM0480



106 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

BLUD PUSKESMAS KEC GROGOL PETAMBURAN

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

30/06/2015

BLUD PUSKESMAS KEC PALMERAH

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

30/06/2015

5859081

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

11110

5840451

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

JL RAYA JOGLO RT 011/02 KOMP PEMADAM KEBAKARAN

11110

58902737

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PUSKESMAS KELURAHAN KEMBANGAN SELATAN

JL RAYA KEMBANGAN RT 007/001

11110

70642117

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1500000001888

PUSKESMAS KELURAHAN KEMBANGAN UTARA

JL RAYA KEMBANGAN RT 005/002

11110

68534570

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

9

1500000001885

PUSKESMAS KELURAHAN MERUYA SELATAN I

JL MERUYA SELATAN RT 07/04

11110

68534571

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

10

1500000001886

PUSKESMAS KELURAHAN MERUYA UTARA

JL RAYA MERUYA ILIR RT 05/04

11110

5843136

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

11

1500000001882

PUSKESMAS KELURAHAN SRENGSENG

JL SRENGSENG RT 01/02

11110

68534572

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

12

1500000001710

RS SILOAM KEBON JERUK

JL RAYA PEJUANGAN KAV 08 KEBON JERUK JAKARTA

11530

25677888

PER/14/062015

RS.TRAUMA CENTRE

29/06/2015

30/06/2016

1

1500000000861

PPKD JAKARTA BARAT

JL KAMAL RAYA NO 2 TEGAL ALUR

2

1500000001684

PUSKESMAS KEC GROGOL PETAMBURAN

JL WIJAYA III BLOK F KOMP TAMAN DUTA MAS

11110

5648379

3

1500000001683

PUSKESMAS KEC PALMERAH

JL PALMERAH BARAT NO 120

11110

5482370

4

1500000001881

PUSKESMAS KECAMATAN KEMBANGAN

JL H. SAABA PERUM WALIKOTA BLOK C7 RT 006/RW 03 MERUYA SELATAN, JAKARTA BARAT

11170

5

1500000001884

PUSKESMAS KELURAHAN JOGLO I

JL MESJID AL-MUBARAK II RT 02/08

6

1500000001883

PUSKESMAS KELURAHAN JOGLO II

7

1500000001887

8

MA11222I

PT SILOAM INTERNATIONAL HOSPITALS


SM0480



107 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

13

1500000000516

RSTC MEDIKA PERMATA HIJAU

JL RAYA KEBAYORAN LAMA NO.64 JAKARTA BARAT

5347411

14

1500000000088

RSTC ROYAL TARUMA

JL DAAN MOGOT NO 34 JAKARTA

56967788

KANTOR CABANG

NO

:

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1500000001023

PUSAT PELATIHAN KERJA DAERAH JAKARTA UTARA

JL. GEREJA TUGU NO.20 SEMPER BARAT, JAKARTA UTARA

2

1500000001818

RS SATYA NEGARA

JL AGUNG UTARA RAYA BLOK A/1 JAKARTA UTARA

3

1500000000497

RUMAH SAKIT PORT MEDICAL CENTER

4

1500000000496

5

1500000001614

MA11222I

:

DR. LIMAN HARIJONO, MARS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/06/032015

RS.TRAUMA CENTRE

02/03/2015

29/02/2016

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

J03- KANTOR CABANG JAKARTA KELAPA GADING

1

KANTOR CABANG

PIMPINAN

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4401066

RUDOLF TAMBUNAN

PER/05/2015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

64715200

DR. GUNAWAN SUSANTO SP.BS

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JLN ENGGANO NO 10 TANJUNG PRIOK

43902350

DR R SUHARBAGYO M

PER/04/032015

RS.TRAUMA CENTRE

19/03/2015

28/02/2016

RUMAH SAKIT PURI MEDIKA

JLN SUNGAI BAMBU NO 5 TANJUNG PRIOK

43903355

DR KARNAIL SINGH

PER/03/032015

RS.TRAUMA CENTRE

04/03/2015

28/02/2016

RUMAH SAKIT UMUM KECAMATAN KOJA

JLN. WALANG PERMAI NO 39 KEC KOJA

RSU KEC KOJA

NOMOR: PER/06/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

14250

J04- KANTOR CABANG JAKARTA RAWAMANGUN


SM0480



108 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

1

7-726516517

KLINIK MITRA CAKUNG

JL. BALAI RAKYAT NO. 38B CAKUNG TIMUR, JAKARTA TIMUR

13910

2

7-725640156

KLINIK NAYAKA 09 DKI JAKARTA

JL RAYA BEKASI TIMUR NO 6 RT 01/02 KLENDER JATINEGARA KAUM

13320

3

7-722461500

KLINIK SUKMA ANGGREK

JL BEKASI TIMUR RAYA KM 18 JATINEGARA - CAKUNG JAKTIM

13310

4

1500000001014

PUSAT PELATIHAN KERJA DAERAH JAKARTA TIMUR

JALAN JATINEGARA BARAT NO 142 JAKTIM

5

1500000001833

PUSKESMAS BIDARA CINA I (TC)

JL OTISTA NO 82

13110

6

1500000001850

PUSKESMAS KEC MATRAMAN (TC)

JL KEBON KELAPA RAYA NO 29 JAKTIM

7

1500000001707

PUSKESMAS KEC. JATINEGARA (TC)

8

1500000001706

9

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. SAID RIZAL

PER/29/122015

RS.TRAUMA CENTRE

21/12/2015

30/11/2016

29688716


PER/27/112015

RS.TRAUMA CENTRE

21/12/2015

30/11/2016

46823314

BUDIMAN

PER/28/112015

RS.TRAUMA CENTRE

21/12/2015

30/11/2016

DIDIK SUPARDI

PER/12/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

85903677

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

13110

8581957

DR HERNI LESTYANINGSIH

PER/15/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

JALAN MATRAMAN RAYA NO. 220 JAKARTA TIMUR

13110

8195146

DR. WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PUSKESMAS KEC. PULOGADUNG (TC)

JL. KAYU PUTIH SELATAN III/2B JAKARTA TIMUR

13110

4890519

DRG KRISTIANI DWI H.

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1500000001837

PUSKESMAS KEL BALI MESTER

JL WEDANA DALAM RT 07/01

13110

85908911

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

10

1500000001847

PUSKESMAS KEL CIPINANG

JL E1 MASJID BAITUSSALAM

13110

4756139

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

11

1500000001843

PUSKESMAS KEL JATI 1

JL PULO ASEM IV

13110

47868535

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

12

1500000001844

PUSKESMAS KEL JATI 2

JL KAPLONGAN I NO 67

13110

4786404

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I


SM0480



109 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

13

1500000001849

PUSKESMAS KEL JATINEGARA KAUM

JL T BADARUDIN RT 001/05

13110

14

1500000001855

PUSKESMAS KEL KAYU MANIS

JL KAYU MANIS 2 NO 27B

13110

15

1500000001842

PUSKESMAS KEL KAYU PUTIH

JL PLAFON I KAMP AMBON

13110

16

1500000001854

PUSKESMAS KEL PISANGAN BARU

JL KEBON SEREH BARAT

17

1500000001848

PUSKESMAS KEL PISANGAN TIMUR I

18

1500000001846

19

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

DR HERNI L

PER/15/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

4710423

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

13110

8507756

DR HERNI L

PER/15/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

JL GADING RAYA I

13110

4755612

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PUSKESMAS KEL PISANGAN TIMUR II

JL H MUGENI III

13110

4756139

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1500000001839

PUSKESMAS KEL RAWA BUNGA

JL JATINEGARA TIMUR IV

13110

8511689

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

20

1500000001845

PUSKESMAS KEL RAWAMANGUN

JL TAMAN JELITA UTARA 5

13110

47864411

DRG KRIS

PER/14/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

21

1500000001853

PUSKESMAS KEL UTAN KAYU 2

JL GALUR SARI RAYA

13110

85909517

DR HERNI

PER/15/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

22

1500000001851

PUSKESMAS KEL UTAN KAYU UTARA

JL KOMPL KEHAKIMAN NO 96

13110

85900059

DR HERNI

PER/15/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

23

1500000001834

PUSKESMAS KEL. BIDARA CINA II

JL NILAM RT 013/11

13110

8571147

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

24

1500000001835

PUSKESMAS KEL. BIDARA CINA III

JL TANJUNG LENGKONG RT 015/07

13110

859175874

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I

4755580


SM0480



110 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1500000001841

PUSKESMAS KEL. CIP. BESAR UTARA

JL CIPINANG PULO MAJA

13110

7734000

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

26

1500000001831

PUSKESMAS KEL. CIPINANG BSR SLTN I

JL CIPINANG JAYA FF NO 8

13110

8511127

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

27

1500000001832

PUSKESMAS KEL. CIPINANG BSR SLTN II

JL PANCAWARGA IV NO 04

13110

85909549

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

28

1500000001838

PUSKESMAS KEL. CIPINANG CEMPEDAK

JL CIPINANG CEMPEDAK IV NO 2

13110

85909474

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

29

1500000001840

PUSKESMAS KEL. CIPINANG MUARA

JL BB I RT 006/015

13110

7408000

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

30

1500000001836

PUSKESMAS KEL. KP MELAYU

JL KEBON PALA I

13110

8515004

DR WINARTO

PER/13/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

31

1500000001852

PUSKESMAS UTAN KAYU 1

JL SKIP UJUNG

13110

8500059

DR HERNI

PER/15/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

32

7-728032798

RS COLUMBIA ASIA RAWAMANGUN

JL KAYU PUTIH RAYA NO. 1, PULOGADUNG JAKTIM

13210

29459999

PT AYUBA UTAMA

PER/30/122015

RS.TRAUMA CENTRE

21/12/2015

30/11/2016

33

1500000000527

RS HARUM SISMA MEDIKA

JL TARUM BARAT, KALI MALANG JAKTIM

8617212

DR RULI NURUL AMAN

PER/09/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

34

7-729931841

RS KHUSUS BEDAH RAWAMANGUN

JL BALAI PUSTAKA RAYA NO. 29-31 RAWAMANGUN

13220

PT EL HAKIM

PER/31/122015

RS.TRAUMA CENTRE

21/12/2015

30/11/2016

35

7-1669163483

RSTC OMNI PULOMAS

JL. PULOMAS BARAT VI NO.20, JAKARTA TIMUR

13210

DR MARIA

PER/01/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

KANTOR CABANG

MA11222I

:

2977 9999

J05- KANTOR CABANG JAKARTA MENARA JAMSOSTEK


SM0480



111 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000212

KLINIK PRATAMA FAKHIRA

JL. MENTENG WADAS TIMUR KELURAHAN PASAR MANGGIS KECAMATAN SETIABUDI

83707368

ERIC SAPUTRA

PER/07/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

2

1400000000416

KLINIK PRATAMA FAKHIRA -AL BARKAH

JL AL BARKAH NO.34 RT/RW 012/03 MANGGARAI SELATAN - TEBET

83707848

ERIC SAPUTRA

PER/08/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

3

1500000000147

KLINIK PRIMARINI

SAHID METROPOLITAN RESIDENCE, JL ANGGREK RAYA KAV 293-295, KARET SETIABUDI

97265271

DR MARINI KUSUMANINGSIH

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

4

1400000000459

KLINIK UTAMA FAKHIRA

JL SAWAH LUNTO NO.83A RT 02 RW 01 KEL. PASAR MANGGIS - SETIABUDI

83707368

ERIC SAPUTRA

PER/06/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

5

1500000001177

RS AGUNG

JL. SULTAN AGUNG NO.67

8294955

YAYASAN KAMAL

PER/02/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6

1400000000366

RS TEBET

JL MT HARYONO KAV. 13

8307540

YAYASAN BINA SEHAT INTERNA

PER/09/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

7

7-140332933

RS. GATSU

JL. GATSU 45

RENI

12345677

RS.TRAUMA CENTRE

27/10/2015

30/10/2015

KANTOR CABANG

NO

KODE PROVIDER

:

12910

J06- KANTOR CABANG JAKARTA CILANDAK

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000170

KLINIK ARAS

JL SRENGSENG SAWAH RT 001/009 JAGAKARSA

7869916

DR. SERI ANNI NASUTION

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1500000000170

KLINIK ARAS

JL SRENGSENG SAWAH RT 001/009 JAGAKARSA

7869916

DR. SERI ANNI NASUTION

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


SM0480



112 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

1500000000839

PPKD JAKARTA SELATAN

JL BUNCIT RAYA NO 440 MAMPANG

7980311

LETTY LESTARI

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

4

1500000000192

RS BHAYANGKARA SESPIMMA POLRI

JL CIPUTAT RAYA NO 40 KEBAYORAN LAMA

7650384

DR JEKSON SURUNG SIMANJUNTAK

PER/02/022015

RS.TRAUMA CENTRE

03/02/2015

03/02/2017

5

1500000000771

RS DR SUYOTO

JL RC VETERAN 178

7342012

RS DR SUYOTO

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

6

1500000001524

RS FATMAWATI

DI JL RS FATMAWATI CILANDAK

7501524

DR.ANDI WAHYUNINGSIH ATTAS

PER/14/052015

RS.TRAUMA CENTRE

15/05/2015

30/04/2016

7

1500000001524

RS FATMAWATI

DI JL RS FATMAWATI CILANDAK

7501524

DR.ANDI WAHYUNINGSIH ATTAS

PER/14/052015

RS.TRAUMA CENTRE

18/05/2015

30/04/2016

8

00000

RS MAYAPADA

JL. LEBAK BULUS 1 KAV. 29, JAKARTA SELATAN

29217777

RS MAYAPADA

PER/10/2015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

9

00000

RS MAYAPADA

JL. LEBAK BULUS 1 KAV. 29, JAKARTA SELATAN

29217777

RS MAYAPADA

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

10

1500000000721

RS MAYAPADA

JL LEBAK BULUS I KAV 20 CILANDAK JAKARTA SELATAN

29217777

RS MAYAPADA

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1500000001942

RS PRIKASIH

JL RS FATMAWATI RAYA NO 74 PONDOK LABU CILANDAK

12430

7504669

DR SUHARNO

PER/19/082015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

12

1500000001935

RS SILOAM TB SIMAPTUPANG

JL RA KARTINI NO 8 CILANDAK

12430

29531900

DR.IRNA S HARDIAWAN

PER/20/082015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

13

1500000000313

RSIA AULIA

JL JERUK RAYA NO 15 JAGAKARSA

7270208

DR GATOT SOERYO KOESUMO

PER/05/2015

RS.TRAUMA CENTRE

03/03/2015

02/03/2016

14

1500000000473

RSIA YADIKA

CIPUTAT RAYA NO 5 KEBAYORAN LAMA SELATAN

7291074

RAJA DL SITORUS

PER/07/2015

RS.TRAUMA CENTRE

30/03/2015

29/03/2016

MA11222I


SM0480



113 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

15

KODE PROVIDER

1

:

KODE PROVIDER

KODE PROVIDER

RUMAH SAKIT HUSADA

:

ALAMAT

JL M KAHFI I NO 27A JAGAKARSA

KODE POS

IKS TELEPON

PIMPINAN NO IKS

12530

KEMENKES

PER/23/092015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

25/11/2015


J07- KANTOR CABANG JAKARTA GAMBIR

NAMA PROVIDER

1500000001453

KANTOR CABANG

NO

RSU KECAMATAN JAGAKARSA

7-492399683

KANTOR CABANG

NO

NAMA PROVIDER

ALAMAT

KODE POS

JLN. RAYA MANGGA BESAR NO.137-139 JAKARTA PUSAT 10730

IKS TELEPON

PIMPINAN NO IKS

6260108

PER/06/062015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/06/2015


J09- KANTOR CABANG JAKARTA CAWANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000402

KLINIK 24 JAM CONDET JAYA

JL. CONDET RAYA NO 18 BATU AMPAR CONDET

081213263 286

DIKI LESTARIONO

PER/TC/02/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

2

1500000000355

KLINIK BUDHI PRATAMA

JL.PONCOL NO.4 RT 01/05 KEL SUSUKAN CIRACAS

87783668

DR. PRASETYO WIDHI BUWONO

PER/TC/04/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

3

1500000000324

KLINIK BUDI PRATAMA KALISARI

JL RAYA KALI SARI NO 52 B PASAR REBO

87782670

DR.PRASETYO WIDHI BUWONO

PER/TC/05/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

4

1500000000375

KLINIK PRATAMA NAYAKA HUSADA 01

JL. RAYA PONDOK GEDE RUKO MOLEK 2 B KEL. LUBANG BUAYA KEC PD. GEDE

8480206

SRI NURYANTI

PER/TC/08/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

5

1500000000374


JL. RAYA LAPAN RUKO PERUMAHAN CAHAYA RESIDENCE KAV 4 PEKAYON JAKARTA TIMUR

29841115

SRI NURYANTI

PER/TC/09/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


SM0480



114 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

6

1500000000356

KLINIK PRATAMA RESTU IBU

7

1500000000403

KLINIK PRATAMA TJAKRA 24 JAM

JL. RAYA BOGOR KM 24 NO. 35 RT001/ RW 01 KEL. SUSUKAN KEC CIRACAS

8

1500000000896

PUSAT PELATIHAN KERJA KHUSUS LAS CONDET

JL RAYA CONDET NO 25 KRAMAT JATI

9

1500000001943

PUSKESMAS KECAMATAN CIPAYUNG

JL BAMBU HITAM NO 104 RT 104/04 KELURAHAN CIPAYUNG

10

1500000001962

PUSKESMAS KEL BAMBU APUS I

11

1500000001963

12

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

87783668

DR.PRASETYO WIDHI BUWONO

PER/TC/03/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

87794539

DR.DARWIN D.TJAKRADIDJAJA

PER/TC/01/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KETUT METRIASIH

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PUSKESMAS

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

13130

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

PUSKESMAS KEL BAMBU APUS II

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

1500000001961

PUSKESMAS KEL LUBANG BUAYA

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

13

1500000001964

PUSKESMAS KELURAHAN CEGER

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

14

1500000001966

PUSKESMAS KELURAHAN CILANGKAP

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

15

1500000001967

PUSKESMAS KELURAHAN CIPAYUNG

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

16

1500000001959

PUSKESMAS KELURAHAN MUNJUL

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

17

1500000001960

PUSKESMAS KELURAHAN PONDOK RANGGON I

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

MA11222I

13110


SM0480



115 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

18

1500000001958

PUSKESMAS KELURAHAN PONDOK RANGGON II

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

19

1500000001965

PUSKESMAS KELURAHAN SETU

13110

PER/13/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

20

1300000000052

RS.UKI

JL. MAYJEN SUTOYO NO. 2 CAWANG

8092317

YAYASAN RS.UKI

PER/TC/12/0520 15

RS.TRAUMA CENTRE

02/05/2015

02/05/2016

21

1300000000052

RS.UKI

JL. MAYJEN SUTOYO NO. 2 CAWANG

8092317

YAYASAN RS.UKI

PER/TC/12/0520 15

RS.TRAUMA CENTRE

02/05/2015

02/05/2016

KANTOR CABANG

NO

:

KODE PROVIDER

J0P- KANTOR CABANG JAKARTA SLIPI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000326

RS BHAKTI MULYA

JL AIPDA KS TUBUN NO 79 SLIPI JAKARTA BARAT

5481625

RS BHAKTI MULYA

PER/05/032015

RS.TRAUMA CENTRE

16/03/2015

16/03/2016

2

1500000000326

RS BHAKTI MULYA

JL AIPDA KS TUBUN NO 79 SLIPI JAKARTA BARAT

5481625

RS BHAKTI MULYA

PER/05/032015

REIMBURSE

16/03/2015

16/03/2016

3

1400000000303

RS PELNI

JL AIPDA KS TUBUN 92-94

5485870

PT PELNI

PER/09/092015

RS.TRAUMA CENTRE

27/01/2016

31/12/2016

KANTOR CABANG

MA11222I

:

10210

J10- KANTOR CABANG JAKARTA PLUIT


SM0480



116 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000903

PUSKESMAS KECAMATAN PENJARINGAN

JL RAYA TELUK GONG NO 2, PENJARINGAN

6694917

FLORIDA MASNIARI S

PER/01/TC/0520 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

2

1500000000902

PUSKESMAS KELURAHAN KAMAL MUARA

JL KAMAL MUARA RT 07/01

55959125

DR INDRA DARMA

PER/01/TC/0520 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

3

1500000000901

PUSKESMAS KELURAHAN KAPUK MUARA

JL KAPUK KAMAL NO 28

6678173

DRG WIDYANINGSIH

PER/01/TC/0520 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

4

1500000000897

PUSKESMAS KELURAHAN PEJAGALAN

JL TELUK GONG KAV RT 003/12, PENJARINGAN

6616245

DRG MARIA PATRICIA M

PER/01/TC/0520 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

5

1500000000899

PUSKESMAS KELURAHAN PENJARINGAN I

JL RAYA PLUIT SELATAN NO 2

669377

TRI

PER/01/TC/0520 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6

1500000000900

PUSKESMAS KELURAHAN PLUIT

JL MUARA ANGKE

6678173

PER/01/TC/0520 15

RS.TRAUMA CENTRE

01/05/2015

31/05/2016

7

1500000000898

PUSKESMAS PENJARINGAN II

JL RAWA BEBEK PASAR ROYAL

66696407

KEMALA

PER/01/TC/0520 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1300000000038

RS ATMAJAYA

JL PLUIT RAYA NO 2

6606127

YAYASAN ATMAJAYA

PER/02/TC/0520 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1500000001828

MA11222I

:

J11- KANTOR CABANG TANGERANG BATUCEPER

NAMA PROVIDER

KLINIK AL HUSAENI

ALAMAT

JL RAYA MAUK KM 16 BUARAN JATI RT02/03

KODE POS

IKS TELEPON

PIMPINAN NO IKS

081707997 49

DR HJ SITI MAKIAH

PER/22/072015



AWAL IKS 01/08/2015


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117 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. ROBBY HILMAN M. SP.M,SPKL

PER/012/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

021559641 17

DR. ROBBY HILMAN M. SP.M,SPKL

PER/011/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7311750

DRDR. TRI SUPRAPTI HANDAJANI, MM

PER/014/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

DR HARYANI

PER/010/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

DR DEDDY DASUKI, MARS

PER/024/102015

RS.TRAUMA CENTRE

30/11/2015

31/10/2016

081777075 3

DR. MELANIE HUSNA

PER/ 009 /062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

5447798

DR ATHENAWATI UNANG

PER/013/062015

KAPITASI

01/06/2015

31/05/2016

DR ATHENAWATI UNANG

PER/013/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JL DAAN MOGOT KM 17 NO 69 RT02/04 KLDRS

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

KLINIK PRATAMA MH THAMRIN CENGKARENG

JL DAAN MOGOT KM 17 NO 69 RT02/04 KLDRS

PER/003/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

1500000001812

KLINIK PRATAMA MH THAMRIN KALIDERES

JL PETA SELATAN RUKO INDAH KALIDERES BLOK A2/2 KLDRS JAKBAR

DR SITI MAKIAH

PER/015/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1400000000530

KLINIK PRATAMA NAYAKA HUSADA 04 DKI

JL TANGKAS BARU NO 1 JAKARTA SELATAN

SRI NURYANTI

PER/027/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

2

1500000001261

KLINIK ARMADA MEDIKA I

JL. KAPUK KAMAL RAYA NO. 34 LT.2

3

1500000001262

KLINIK ARMADA MEDIKA III

JL. KAPUK KAMAL RAYA NO. 34 LT.1

4

1500000001265

KLINIK DOKTER PRAKTEK PERORANGAN DAN DOKTER KELUARGA DR TRI SUPRAPTI HANDAJANI,MM

JL. CENDRAWASIH RAYA 2 CENGKARENG BARAT

5

1500000001264

KLINIK DR HARYANI

JL. KAPUK KAMAL RAYA, RAWA MELATI NO. 47 JAKARTA BARAT

6

7-587445633

KLINIK DUTA MEDIKA

JL. DAAN MOGOT KM. 20 KEBON BESAR BATU CEPER TANGERANG

7

1500000001263

KLINIK KAINA HEALTH CARE

JL. PETA SELATAN NO. 6 KALIDERES

8

07321

KLINIK MEDIKA BINA SEJAHTERA

JL KOSAMBI UTARA RAYA BLOK E1 NO 11A

9

1500000001288

KLINIK MEDIKA BINA SEJAHTERA

JL. KOSAMBI UTARA RAYA BLOK E1 NO. 11 A

10

1500000000145

KLINIK PRATAMA MH THAMRIN CENGKARENG

11

1500000000145

12

13

MA11222I

15211

11110

5456027


SM0480



118 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

14

7-757562796

KLINIK PRATAMA NAYAKA HUSADA 04 DKI

RUKO 100 JL KP MELAYU SALEMBARAN KP BISKEN RT 01/RW13 KP MELAYU TIMUR

15141

SRI NURYANTI

PER/027/102015

RS.TRAUMA CENTRE

02/12/2015

30/09/2016

15

7-589033023

PBDU YADIKA TEGAL ALUR

JL. KAMAL RAYA BLOK H.7 NO. 7 - 11, TEGAL ALUR KALIDERES

11710

DR SAPTAJI

PER/025/102015

RS.TRAUMA CENTRE

30/11/2015

31/10/2016

16

7-1459450363

RS HERMINA DAAN MOGOT

JL KINTAMANI RAYA NO 2 DAAN MOGOT BARU

11710

DR I ICHSAN HANAFI MARS

PER/004/012016

RS.TRAUMA CENTRE

22/01/2016

17/01/2017

17

1500000000146

RS KARANG TENGAH MEDIKA

JL KARYAWAN IV CILEDUG KARANG TENGAH

7336699

PER/01/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

18

1500000000146

RS KARANG TENGAH MEDIKA

JL KARYAWAN IV CILEDUG KARANG TENGAH

7336699

PER/005/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

19

1500000001260

RS MITRA HUSADA

JL KAMPUNG MELAYU BARAT NO 11 A TELUK NAGA

082125449 938

DR HENDRY WIJAYA

PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

20

1400000000006

RSUD CENGKARENG

JL KAMAL RAYA BUMI CENGKARENG INDAH

54382793

DR SUGINO KESUMA

PER/033/122015

RS.TRAUMA CENTRE

30/12/2015

30/11/2016

21

1500000001976

RUMAH SAKIT IBU DAN ANAK BUN

JL KOSAMBI RAYA NO 2 TANGERANG

021706107 35

DR ELIYANAH

PER/01/RSTC/10 2015

RS.TRAUMA CENTRE

15/10/2015

14/10/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1500000000841

MA11222I

:

J12- KANTOR CABANG JAKARTA PULOGADUNG

NAMA PROVIDER PUSAT PELATIHAN KERJA PENGEMBANGAN INDUSTRI (PPKPI) PASAR REBO

ALAMAT

JL RAYA BOGOR KM 23 PASAR REBO

KODE POS

IKS TELEPON

PIMPINAN NO IKS

8400724

SUMINARSIH WAGE

PER/06/052015



AWAL IKS 01/05/2015


SM0480



119 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1500000001859

PUSKESMAS KECAMATAN CAKUNG

JL RAYA BEKASI KM.18

13930

4614700

PER/12/072015

FFS

06/07/2015

30/06/2016

3

1500000001861

PUSKESMAS KELURAHAN CAKUNG BARAT

JL RAYA TIPAR CAKUNG BARAT

13910

46829709

PER/12/072015

FFS

06/07/2015

30/06/2016

4

1500000001863

PUSKESMAS KELURAHAN CAKUNG TIMUR

JL BALAI RAKYAT NO 87

13910

4682910

PER/12/072015

FFS

06/07/2015

30/06/2016

5

1500000001867

PUSKESMAS KELURAHAN JATINEGARA

JL RAYA BEKASI KM 17

13920

4612345

PER/12/072015

FFS

06/07/2015

30/06/2016

6

1500000001868

PUSKESMAS KELURAHAN PENGGILINGAN ELOK

PERUMAHAN ANEKA ELOK

13920

4807827

PER/12/072015

FFS

06/07/2015

30/06/2016

7

1500000001864

PUSKESMAS KELURAHAN PENGGILINGAN PIK

KOMP PIK PENGGILINGAN

13940

46829710

PER/12/072015

FFS

06/07/2015

30/06/2016

8

1500000001865

PUSKESMAS KELURAHAN PULOGEBANG

JL RAYA STASIUN KM 4 CAKUNG

13940

4807828

PER/12/072015

FFS

06/07/2015

30/06/2016

9

1500000001862

PUSKESMAS KELURAHAN RAWA TERATAI

JL RAYA BEKASI KM 21 CAKUNG

13920

46829720

PER/12/072015

FFS

06/07/2015

30/06/2016

10

1500000001860

PUSKESMAS KELURAHAN UJUNG MENTENG

JL RAYA BEKASI KM.26

13960

46828217

PER/12/072015

FFS

06/07/2015

30/06/2016

11

1500000000247

RS ANTAM MEDIKA

JL RAYA PEMUDA NO 1A

29378939

PER/TC/01/0320 15

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

12

7-1362178499

RS HARAPAN JAYAKARTA

JL BEKASI TIMUR RAYA NO.6 KM 18 PULOGADUNG

PER/TC/01/0120 16

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

13

1200000000004

RS HARAPAN JAYAKARTA

JL BEKASI TIMUR RAYA NO 6 KM 18 PULOGADUNG

PER/TC/01/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

13210

46822879

4603916

DR. SRI HARTATI


SM0480



120 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

14

KODE PROVIDER

1

:

KODE PROVIDER

RS GANDARIA

:

KODE PROVIDER

NAMA PROVIDER

1500000000656

KLINIK PERMATA MEDIKA 1

2

1500000000591

RS ISLAM JAKARTA SUKAPURA

3

1500000000290

RS. FIRDAUS

MA11222I

:

KODE POS

JALAN RAYA PONDOK KOPI

IKS TELEPON

PIMPINAN NO IKS

8610471

PER/11/052015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/06/2015


ALAMAT

KODE POS

JLN GANDARIA TENGAH II NO 6-14 JAK SEL

IKS TELEPON

PIMPINAN NO IKS

7203311

DR .H.J ROESLANI S,SP THT

05/042015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/04/2015


J14- KANTOR CABANG JAKARTA CILINCING

1

KANTOR CABANG

ALAMAT

J13- KANTOR CABANG JAKARTA KEBAYORAN BARU

NAMA PROVIDER

1500000000476

KANTOR CABANG

NO

RSTC RS ISLAM PONDOK KOPI

1100000000029

KANTOR CABANG

NO

NAMA PROVIDER

ALAMAT

EMPER RAYA NO.22 RT.010/002

KODE POS

IKS TELEPON

PIMPINAN NO IKS

4303619

DR.EMPAT PATONAH

4400781 KOMP BEA CUKAI JL SIAK J5/14 JAKARTA UTARA

4407322

DR UNTUNG SUGIHARTO

TIPE IKS

AWAL IKS

AKHIR IKS

02/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PER/02/04015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PER/01/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

J15- KANTOR CABANG JAKARTA MANGGA DUA


SM0480



121 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

1

1500000001347

PUSKESMAS KECAMATAN TAMANSARI

JL MADU NO.10 MANGGABESAR TAMANSARI

6247319

2

1500000001350

PUSKESMAS KELURAHAN KEAGUNGAN

JL KEBON SAYUR I NO.6

3

1500000001362

PUSKESMAS KELURAHAN KRUKUT

4

1500000001349

5

TIPE IKS

AWAL IKS

AKHIR IKS

PER/007/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6281130

PER/007/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JL KRUKUT LIO

6319817

PER/007/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PUSKESMAS KELURAHAN MANGGA BESAR

JL BLUSTRU NO.16

6595342

PER/007/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1500000001351

PUSKESMAS KELURAHAN MAPHAR

JL KEBON JERUK X

6592603

PER/007/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6

1500000001348

PUSKESMAS KELURAHAN TAMANSARI

JL MANGGA BESAR XIII

6247319

DR HERWIN M

PER/007/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000000596

RSU KECAMATAN PADEMANGAN

JL BUDI MULYA RAYA PADEMANGAN

6452346

DR SITI RACHMI

PER/005/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

DR HERWIN

J16- KANTOR CABANG JAKARTA SUDIRMAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

1

2015000000001


JL GATOT SUBROTO LANTAI GROUND

5207797

2

2015000000002

RS JAKARTA

JLN GARNISUN NO 1 JEND SUDIRMAN

5732241

MA11222I

DR HERWIN MEIFENDY

PT JASMETRA

TIPE IKS

AWAL IKS

AKHIR IKS

PER/TC/08/0120 15

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

001/MKT/IKSMITRA/3/2015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015


SM0480



122 / 322 09-02-2016 18:49:59


NO

:

KODE PROVIDER

J17- KANTOR CABANG JAKARTA MAMPANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1502201500002

KLINIK RESTU IBU II

JL. SWADAYA NO. 54 PEJATEN JAKARTA SELATAN

78840267

DR. PRASETYO WIDHI BUWONO,SP.PD

PER/03/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

2

1806201500004

RS ZAHIRAH

JL. SIRSAK NO.21 JAGAKARSA JAKARTA SELATAN

7872210

ROBI HARI SETIAWAN,SE,MM

PER/12/062015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

3

1806201500004

RS ZAHIRAH

JL. SIRSAK NO.21 JAGAKARSA JAKARTA SELATAN

7872210

ROBI HARI SETIAWAN,SE,MM

001/RSZDIR/PKS/VI/201 5

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

4

2505201500003

RSU KECAMATAN MAMPANG PRAPATAN

JL. KAPTEN TENDEAN NO.9 JAKARTA SELATAN

79192187

DR. DEWI SRI RACHMAWATI SP.A

PER/09/052015

RS.TRAUMA CENTRE

21/05/2015

20/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

K00- KANTOR CABANG BANDUNG SUCI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001896

BIOFIT HEALTH CENTER

JL. WR SUPRATMAN NO. 69, BANDUNG

40114

7271451

NENDEN SUHARTINI

PER/25/0715

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

2

1500000001896

BIOFIT HEALTH CENTER

JL. WR SUPRATMAN NO. 69, BANDUNG

40114

7271451

NENDEN SUHARTINI

PER/01/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

3

1500000000837

KLINIK KIMIA FARMA 14

JL. CIHAMPELAS 7 BANDUNG

4201596

PT KIMIA FARMA (PERSERO) TBK

PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

4

1500000000837


JL. CIHAMPELAS 7 BANDUNG

4201596


PER/09/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

5

1500000000834


JL.IR.H.JUANDA 69 BANDUNG

4203331


PER/11/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I


SM0480



123 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6

1500000000834


JL.IR.H.JUANDA 69 BANDUNG

4203331


PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

7

1500000000835

KLINIK KIMIA FARMA SETIABUDI

JL.SETIABUDI 36 BANDUNG

2038048


PER/12/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

8

1500000000835

KLINIK KIMIA FARMA SETIABUDI

JL.SETIABUDI 36 BANDUNG

2038048


PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

9

1500000000836

KLINIK KIMIA FARMA SINDANGLAYA

JL. SUKAMISKIN 126B BANDUNG

7178664


PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

10

1500000000836

KLINIK KIMIA FARMA SINDANGLAYA

JL. SUKAMISKIN 126B BANDUNG

7178664


PER/13/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

11

1500000000859

KLINIK ALIVIA MEDIKA

JL. PASUNDAN NO. 107, BANDUNG

87805328

YUDI PRIHARTANTO

PER/02/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

12

1500000000859

KLINIK ALIVIA MEDIKA

JL. PASUNDAN NO. 107, BANDUNG

87805328

YUDI PRIHARTANTO

PER/15/ 042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

13

1500000000860

KLINIK AMANAH

JL. PHH MUSTOFA NO. 124, BANDUNG.

7279705

YUDI PRIHARTANTO

PER/03/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

14

1500000000860

KLINIK AMANAH

JL. PHH MUSTOFA NO. 124, BANDUNG.

7279705

YUDI PRIHARTANTO

PER/18/ 052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

15

1500000000805

KLINIK BINA MASYARAKAT SEHAT (BMS)

JL. AH NASUTION NO. 96 A BANDUNG

7801861

DR H YONO SUDIYONO MARS, MHKES

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

1500000000805

KLINIK BINA MASYARAKAT SEHAT (BMS)

JL. AH NASUTION NO. 96 A BANDUNG

7801861

DR H YONO SUDIYONO MARS, MHKES

PER/16/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

17

1500000000855

KLINIK HIKMAH

JL. PESANTREN NO. 8A, RT 01/04, KELURAHAN SUKAMISKIN, KECAMATAN ARCAMANIK, BANDUNG

814 254 80

DRG NIA LESTARI

PER/05/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I


SM0480



124 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

18

1500000000855

KLINIK HIKMAH

JL. PESANTREN NO. 8A, RT 01/04, KELURAHAN SUKAMISKIN, KECAMATAN ARCAMANIK, BANDUNG

814 254 80

DRG NIA LESTARI

PER/12/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

19

1500000000854

KLINIK HIKMAH DUA

JL. IBRAHIM AJI NO. 145, KIARA CONDONG, BANDUNG

81525480

NANO ROHANA

PER/06/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

20

1500000000854

KLINIK HIKMAH DUA

JL. IBRAHIM AJI NO. 145, KIARA CONDONG, BANDUNG

81525480

NANO ROHANA

PER/13/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

21

1500000000585

KLINIK ITENAS

JALAN PHH MUSTOFA NO. 23 , BANDUNG

PT. RS PADJADJARAN

PER/07/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

22

1500000000585

KLINIK ITENAS

JALAN PHH MUSTOFA NO. 23 , BANDUNG

PT. RS PADJADJARAN

PER/004/04/2015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

23

1500000000584

KLINIK KIARA HUSADA

JALAN IBRAHIM ADJIE NO. 25 (TERS KIRCON) BANDUNG

7564929

PT RUMAH SAKIT PADJADJARAN

PER/03/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

24

1500000000584

KLINIK KIARA HUSADA

JALAN IBRAHIM ADJIE NO. 25 (TERS KIRCON) BANDUNG

7564929

PT RUMAH SAKIT PADJADJARAN

PER/08/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

25

1500000000833


JL. BUAH BATU 59 BANDUNG

7305019


PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

26

1500000000833


JL. BUAH BATU 59 BANDUNG

7305019


PER/10/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

27

1500000000553

KLINIK MITRA MULYA

JL. AH NASUTION NO. 20 RT 001/014, CIPADUNG KIDUL, PANYILEUKAN, BANDUNG

7804489

MULYATI

PER/05/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

28

1500000000553

KLINIK MITRA MULYA

JL. AH NASUTION NO. 20 RT 001/014, CIPADUNG KIDUL, PANYILEUKAN, BANDUNG

7804489

MULYATI

PER/14/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

29

1500000000704

KLINIK PRATAMA SEHATI

RUKO BUMI MAS KENCANA KAV O. JL. AH NASUTION 928, CIKADUT, BANDUNG

7237337

DRG YUDHIASTUTI NUNING HARINI

PER/08/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

30

1500000000704


RUKO BUMI MAS KENCANA KAV O. JL. AH NASUTION 928, CIKADUT, BANDUNG

7237337

DRG YUDHIASTUTI NUNING HARINI

PER/15/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

31

1500000000600

KLINIK PRATAMA SELAMAT

JL. TERUSAN BUAH BATU NO. 227 BANDUNG

88881585

DR MAGDALIZA

PER/16/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

32

1500000000600

KLINIK PRATAMA SELAMAT

JL. TERUSAN BUAH BATU NO. 227 BANDUNG

88881585

DR MAGDALIZA

PER/06/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

33

1500000000853

KLINIK UJUNG BERUNG

JL. RUMAH SAKIT NO.5 RT. 006/07, PAKEMITAN, CINAMBO, BANDUNG

91752269

DR HARIS FATAH

PER/17/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

34

1500000000853

KLINIK UJUNG BERUNG

JL. RUMAH SAKIT NO.5 RT. 006/07, PAKEMITAN, CINAMBO, BANDUNG

91752269

DR HARIS FATAH

PER/14/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

35

1500000000743

KLINIK UTAMA AL ISLAM

JL. AWIBITUNG NO. 29-31 CICADAS BANDUNG

7208284

YAYASAN RUMAH SAKIT ISLAM-KSWI JAWA BARAT

PER/18/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

36

1500000000743

KLINIK UTAMA AL ISLAM

JL. AWIBITUNG NO. 29-31 CICADAS BANDUNG

7208284

YAYASAN RUMAH SAKIT ISLAM-KSWI JAWA BARAT

PER/10/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

37

1500000000708

KLINIK UTAMA MEDIKA ANTAPANI

JALAN PURWAKARTA NO.3 ANTAPANI BANDUNG

081563944 143

DRA HJ LENTE MELANIE

PER/09/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

38

1500000000708

KLINIK UTAMA MEDIKA ANTAPANI

JALAN PURWAKARTA NO.3 ANTAPANI BANDUNG

081563944 143

DRA HJ LENTE MELANIE

PER/19/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

39

1500000000801

RS MATA CICENDO

JL. CICENDO NO. 4 BANDUNG

4231280

KEMENKES

PER/11/042015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

40

1500000000801

RS MATA CICENDO

JL. CICENDO NO. 4 BANDUNG

4231280

KEMENKES

PER/20/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

41

1100000000014

RS PINDAD

JL. GATOT SUBROTO NO.517 PAPANGGUNGAN BANDUNG

7322468

PER/21/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

42

1100000000014

RS PINDAD

JL. GATOT SUBROTO NO.517 PAPANGGUNGAN BANDUNG

43

1100000000015

RS SARININGSIH

44

1100000000015

45

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL. LL RE MARTADINATA NO. 9

PER/22/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

RS SARININGSIH

JL. LL RE MARTADINATA NO. 9

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

1500000001399

RS. SALAMUN

JL. CIUMBELUIT NO. 203, BANDUNG, JAWA BARAT, 40142

2032090

DR. BAMBANG S. GUNADI, SP.RAD., MARS.,

PER/20/ 052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

46

1500000001399

RS. SALAMUN

JL. CIUMBELUIT NO. 203, BANDUNG, JAWA BARAT, 40142

2032090

DR. BAMBANG S. GUNADI, SP.RAD., MARS.,

PER/23/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

47

1400000000159

RS. SANTO YUSUP

JL. CIKUTRA NO. 7 BANDUNG

7208172

PERKUMPULAN "PERHIMPUNAN SANTO BORROMEUS"

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

48

1500000001934

RSKB HALMAHERA SIAGA

JL.L.L.R.E.MARTADINATA NO.28, JAWA BARAT 40115

40115

4206061

PROF DR M AHMAD DJOJOSUGITO, DR, SP OT

PER/24/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

49

1500000001934

RSKB HALMAHERA SIAGA

JL.L.L.R.E.MARTADINATA NO.28, JAWA BARAT 40115

40115

4206061

PROF DR M AHMAD DJOJOSUGITO, DR, SP OT

PER/27/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

50

1500000000697

RSU BUNGSU

JL. VETERAN NO. 6, BANDUNG

4231550

DR. LILIAN MELATTIE E. NORE

PER/07/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

51

1500000000697

RSU BUNGSU

JL. VETERAN NO. 6, BANDUNG

4231550

DR. LILIAN MELATTIE E. NORE

PER/25/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

52

1500000000460

RSUD KOTA BANDUNG

JL. RUMAH SAKIT NO. 22, UJUNGBERUNG

7811794

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

53

1500000000460

RSUD KOTA BANDUNG

JL. RUMAH SAKIT NO. 22, UJUNGBERUNG

7811794

PER/26/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I

7322468


SM0480



127 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

54

1500000001936

RSUP HASAN SADIKIN BANDUNG

JL. RAYA PASTEUR NO 36, BANDUNG

40161

2034953

KEMENKES

PER/27/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

55

1500000001936

RSUP HASAN SADIKIN BANDUNG

JL. RAYA PASTEUR NO 36, BANDUNG

40161

2034953

KEMENKES

PER/27025015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

K01- KANTOR CABANG BEKASI KOTA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000698

KLINIIK TC ANNISA

JL RAYA KAMPUNG BARU KEMANG RT 03/04 JATIBENING BARU PD GEDE BEKASI

PER/17/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

2

1500000000698

KLINIIK TC ANNISA

JL RAYA KAMPUNG BARU KEMANG RT 03/04 JATIBENING BARU PD GEDE BEKASI

PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

3

1400000000352

KLINIK TC AMUNA MEDIKA

JL SILIWANGI KM 12 NAROGONG BT.GEBANG

TATI NURHAYATI

PER/49/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

4

1500000000830

KLINIK TC CAHAYA ASYPA

TAMAN NAROGONG INDAH BLOK C.18 NO 1

ALAN

PER/24/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

5

1500000000830

KLINIK TC CAHAYA ASYPA

TAMAN NAROGONG INDAH BLOK C.18 NO 1

ALAN

PER/24/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

6

1500000001938

KLINIK TC CEMPAKA MEDICAL CENTER

JL SETIA MEKAR NO 3 TAMBUN

DR. TJEPY F ALOWIE, MSC, SPOK

PER/34/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

7

1500000000699

KLINIK TC HANDAYANI MEDIKA

JL RAYA KALIMALANG NO 9 DS CIBUNTU CIBITUNG BEKASI

PER/18/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I

32960966

17216

8807111


SM0480



128 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

8

1500000000699

KLINIK TC HANDAYANI MEDIKA

JL RAYA KALIMALANG NO 9 DS CIBUNTU CIBITUNG BEKASI

9

1400000000356

KLINIK TC HARAPAN BARU

JL HARAPAN BARU BARAT NO 51

10

1500000000744

KLINIK TC MAHADINA

11

1500000000744

12

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/18/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/35/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

JL RAYA SELANG JATI RT 03/03 WANAJAYA CIBITUNG

PER/22/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

KLINIK TC MAHADINA

JL RAYA SELANG JATI RT 03/03 WANAJAYA CIBITUNG

PER/22/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

1500000000739

KLINIK TC MAHADINA MEDIKA

JL BOSHI RAYA NO 9 WANASARI CIBITUNG

PER/21/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

13

1400000000359

KLINIK TC MEDIKA HARMONY

JL FATAHILLAH NO 1 CIKARANG BARAT

PER/51/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

14

1500000000913

KLINIK TC MH THAMRIN BEKASI

JL HM JOYOMARTONO NO 31B BEKASI TIMUR

PER/25/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

15

1500000000913

KLINIK TC MH THAMRIN BEKASI

JL HM JOYOMARTONO NO 31B BEKASI TIMUR

PER/25/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

16

1400000000355

KLINIK TC MULIA MEDIKA

JL KALI ABANG TENGAH NO 1 A

88987741

PER/35/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

17

1400000000354

KLINIK TC NAYAKA 01 BEKASI

JL. IR. H. JUANDA KAV. 143 RUKO NO. 9A-10

88958142

PER/37/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

18

1400000000353

KLINIK TC NAYAKA 04 BEKASI

JL RAYA PERJUANGAN NO.26 TELUK PUCUNG

89132587

PER/37/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

19

1500000001328

KLINIK TC SETO HASBADI 01

JL SEROJA NO 10A KA CEGER RT 06/02 HARAPAN JAYA

PER/30A/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

8862936

89110027


SM0480



129 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

20

1500000001328


JL SEROJA NO 10A KA CEGER RT 06/02 HARAPAN JAYA

PER/30A/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

21

1500000001327


JL RAYA SULTAN AGUNG BLOK O NO 27 MEDAN SATRIA

PER/30B/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

22

1500000001327


JL RAYA SULTAN AGUNG BLOK O NO 27 MEDAN SATRIA

PER/30B/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

23

1500000001326


JL RAYA IMAM BONJOL NO 01 TELAGA ASIH CIKARANG BARAT

PER/30C/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

24

1500000001326


JL RAYA IMAM BONJOL NO 01 TELAGA ASIH CIKARANG BARAT

PER/30C/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

25

1500000001254

KLINIK TC SRITINA

JL IMAM BONJOL NO 8 RT 01/01 TELAGA MURNI CIKARANG BARAT

PER/28/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

26

1500000001254

KLINIK TC SRITINA

JL IMAM BONJOL NO 8 RT 01/01 TELAGA MURNI CIKARANG BARAT

PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

27

1500000000745

KLINIK TC VILA BEKASI INDAH

VILLA BEKASI INDAH JL GUNUNG DIENG RAYA BLOK B3 NO 12 TAMBUN

PER/20/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

28

1400000000358

KLINIK TC WIRATAMA

KOMP PLAZA METROPOLITAN BLOK A.3/8 TAMBUN SEL

88326918

PER/50/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

29

1400000000357

KLINIK TC YAKESTI BEKASI

JL RAYA NAROGONG KM 7 NO 45

8253516

M SYAFI'I MA'ARIF

PER/35/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

30

1500000001947

RS TC BUNDA MULIA

JL IMAM BONJOL NO 80 WARUNG BONGKOK RT 008/008 SUKADANAU CIKARANG BARAT

8900579

DIONISIUS SAGIGATA YASIDA LAWING, ST

PER/47/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

31

1400000000120

RSTC ANNA MEDIKA

JL RAYA PERJUANGAN NO.45, HARAPAN BARU

88882211

PT ANNA MEDIKA

PER/23/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I

17520


SM0480



130 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

32

1400000000365

RSTC AWAL BROS BEKASI

JL KH NOER ALI KAYURINGIN JAYA BEKASI SELATAN

8868888

33

1400000000715

RSTC BELLA

JL IR H JUANDA NO 141 BEKASI

8801775

34

1400000000121

RSTC CIBITUNG MEDIKA

J LRAYA BOSIH NO.117 CIBITUNG

88323444

35

1400000000121



36

1400000000121



37

7-1086708933

RSTC HERMINA BEKASI

JL KEMAKMURAN NO 39 MARGAJAYA BEKASI

38

7-976111831

RSTC HERMINA GALAXY

39

1500000001968

40

AWAL IKS

AKHIR IKS

PER/36/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

PER/59/122015

RS.TRAUMA CENTRE

01/12/2015

31/12/2016

PT ADHI PUTRA MEDIKA

PER/01/012016

RS.TRAUMA CENTRE

09/02/2016

31/12/2016

88323444


PER/19/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2015

88323444


PER/19/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

17133

DR. ADIA SUSANTI, MM

PER/61/122015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

JL GARDENIA RAYA BLOK BA I NO 11 GRAND GALAXY CITY BEKADI SELATAN

17141

DR. IRMA SURYANI

PER/60/122015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

RSTC HERMINA GRAND WISATA

FESTIVAL BOULEVARD GRAND WISATA DS LAMBANG SARI KEC TAMBUN SELATAN BEKASI

17217

PER/55/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

1100000000020

RSTC HOSANA MEDICA

JL PRAMUKA NO.12 RAWA LUMBU NAROGONG

8221570

JOHANES POSO

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

41

1100000000020

RSTC HOSANA MEDICA


8221570

JOHANES POSO

PER/02/012016

RS.TRAUMA CENTRE

09/02/2016

31/12/2016

42

1100000000020

RSTC HOSANA MEDICA


8221570

JOHANES POSO

PER/27/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2015

43

1500000000681

RSTC KARYA MEDIKA I

JL RAYA IMAM BONJOL NO 9B CIKARANG BARAT

29493400

DR NOVITA

PER/01/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

DR DINI HANDAYANI MARS

TIPE IKS

82651212


SM0480



131 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

44

1500000001251

RSTC MULTAZAM MEDIKA

PERUM JATIMULYA NO.1 TAMBUN

45

7-976569533

RSTC PERMATA BEKASI

JL LEGENDA RAYA NO 9 MUSTIKA JAYA

46

1500000001329

RSTC SETO HASBADI

JL RAYA SEROJA NO 19 HARAPAN JAYA

47

1500000001817

RSTC TAMAN HARAPAN BARU

JL KALI ABANG TENGAH NO 2 RT 4/23 PEJUANG MEDAN SATRIA

48

1500000001255

RSTC TIARA BEKASI

JL RAYA BABELAN

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

IKS TELEPON

PIMPINAN NO IKS

17155

DR. LISA LUTRISA, MARS

17111

TIPE IKS

AWAL IKS

AKHIR IKS

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/58/122015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/33/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

K02- KANTOR CABANG BOGOR KOTA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000252

BATIK MEDICAL CENTER

JL KAYUMANIS NO 09 RT 02/ 01 KEL CIBINONG

295333182

CV BATIK ESTETIKA INDONESIA

PER/ 21/ 022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

2

1500000000252

BATIK MEDICAL CENTER

JL KAYUMANIS NO 09 RT 02/ 01 KEL CIBINONG

295333182

CV BATIK ESTETIKA INDONESIA

PER/16/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

3

1400000000415

BP BUNDA MULIA

JL SOMANTRI NO 11 RT 003/004 DS MEKAR MULYA PARUNG PANJANG

5978058

HJ UPEN SUPENTI

PER/07/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

4

1400000000415

BP BUNDA MULIA

JL SOMANTRI NO 11 RT 003/004 DS MEKAR MULYA PARUNG PANJANG

5978058

HJ UPEN SUPENTI

PER/ 12/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


SM0480



132 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1500000000073

BP NURDIN WAHID

JL HM ASHARI NO 22 CIBINONG

87916739

YANNI MAUTIA S R

PER/ 16/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

6

1500000000073

BP NURDIN WAHID

JL HM ASHARI NO 22 CIBINONG

87916739

YANNI MAUTIA S R

PER/12/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

7

7-1588689223

KLINIK AULIA MEDIKA

JL.LANDBAW NO.01

16810

87902900

SUSINAH HARUN

PER/22/012016

RS.TRAUMA CENTRE

04/02/2016

31/12/2016

8

7-1588689227

KLINIK MH THAMRIN

JL.RAYA PUNCAK KM 75 CIPAYUNG

16770

025182561 72

YAYASAN MH THAMRIN

PER/25/012016

RS.TRAUMA CENTRE

04/02/2016

31/12/2016

9

1400000000311

KLINIK PELITA SEHAT SIMPANG POMAD

JL RAYA CIBULUH NO 8-9 KEL CIBULUH KEC KOTA BOGOR UTARA

DR JUNAIDY FREDY

PER/23/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

10

7-1670259391

KLINIK PERMATA HUSADA

JL.RAYA BABAKAN MADANG NO.10

DRG.WIWIK DWI ARYANI, MARS

PER/24/012016

RS.TRAUMA CENTRE

04/02/2016

31/12/2016

11

1500000001536

PUSKESMAS JASINGA

JL.LET.SAYUTI JASINGA

085780041 002

PER/21/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

12

1500000001536

PUSKESMAS JASINGA

JL.LET.SAYUTI JASINGA

085780041 002

PER/26/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

13

1400000000310

RS ATANG SANJAYA

JL SARIJO NO 1 ATANG SANJAYA KEMANG

7532946

AURI

PER/04/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

14

1400000000310

RS ATANG SANJAYA

JL SARIJO NO 1 ATANG SANJAYA KEMANG

7532946

AURI

PER/ 09/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

15

1500000000314

RS BHAYANGKARA TK IV BOGOR

JALAN KAPTEN MUSLIHAT NO 18

8348987

POLRI

PER/ 19/ 022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

16

1500000000314

RS BHAYANGKARA TK IV BOGOR

JALAN KAPTEN MUSLIHAT NO 18

8348987

POLRI

PER/17/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

MA11222I

16810

87952811


SM0480



133 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1200000000006

RS BINA HUSADA TC

JL MAYOR OKING JAYAATMAJA

87911000

DR HARSONO

PER/01/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

18

1200000000006

RS BINA HUSADA TC


87911000

DR HARSONO

PER/ 04/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

19

1500000000071

RS FAMILY MEDICAL CENTER TC

JL RAYA JAKARTA BOGOR KM 51 SUKARAJA

PT JALAMAS PUTRA REJEKI

PER/10/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

20

1500000000071

RS FAMILY MEDICAL CENTER TC

JL RAYA JAKARTA BOGOR KM 51 SUKARAJA

PT JALAMAS PUTRA REJEKI

PER/ 03/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

21

1400000000286

RS ISLAM BOGOR

JALAN PERDANA RAYA NO 22

8316822

YYS RS ISLAM BOGOR

PER/26/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

22

1400000000284

RS KARYA BHAKTI PRATIWI

JALAN RAYA DRAMAGA KM 7

8626868

YYS KARYA BHAKTI PRATIWI

PER/02/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

23

1400000000284

RS KARYA BHAKTI PRATIWI

JALAN RAYA DRAMAGA KM 7

8626868

YYS KARYA BHAKTI PRATIWI

PER/ 07/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

1400000000713

RS MELANIA

JALAN PAHLAWAN NO 91 BOGOR SELATAN

8321196

PT SPAA MEDIKA

PER/09/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

25

1400000000713

RS MELANIA

JALAN PAHLAWAN NO 91 BOGOR SELATAN

8321196

PT SPAA MEDIKA

PER/ 15/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

1500000000074

RS PMI BOGOR TC

JL PAJAJARAN NO 80

YAYASAN PMI

PER/13/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

27

1500000000074

RS PMI BOGOR TC

JL PAJAJARAN NO 80

YAYASAN PMI

PER/ 01/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

28

1400000000309

RS SALAK BOGOR


KESDAM SILIWANGI

PER/ 08/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

8344609


SM0480



134 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

29

1400000000309

RS SALAK BOGOR


8344609

KESDAM SILIWANGI

PER/03/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

30

1500000000072

RS SENTRA MEDIKA CIBINONG TC


87909999

DRG HERMAN

PER/11/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

31

1500000000072

RS SENTRA MEDIKA CIBINONG TC


87909999

DRG HERMAN

PER/ 05/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

32

1400000000333

RS TRIMITRA

JL RAYA JAKARTA BOGOR KM 43 CIBINONG

8763055

DR EMA SUMARSAH

PER/05/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

33

1400000000333

RS TRIMITRA

JL RAYA JAKARTA BOGOR KM 43 CIBINONG

8763055

DR EMA SUMARSAH

PER/ 11/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

34

1500000000637

RS VANIA

JL SILIWANGI NO 11 KEL SUKASARI BOGOR TIMUR

PER/ 24/ 052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

35

1500000000637

RS VANIA

JL SILIWANGI NO 11 KEL SUKASARI BOGOR TIMUR

PER/19/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

36

1500000000075

RSD CIBINONG TC

JL DESA TENGAH NO 27 CIBINONG

PEMDA KAB BOGOR

PER/14/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

37

1500000000075

RSD CIBINONG TC

JL DESA TENGAH NO 27 CIBINONG

PEMDA KAB BOGOR

PER/ 02/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

38

1500000000636

RSIA ANNISA

JL RAYA KARANGGAN NO 2 DS PUSPASARI CITEUREUP

YYS ANNISA

PER/ 23/ 052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

39

1500000000636

RSIA ANNISA

JL RAYA KARANGGAN NO 2 DS PUSPASARI CITEUREUP

YYS ANNISA

PER/18/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

40

1500000001535

RSUD CIAWI BOGOR

JL.RAYA PUNCAK NO.479 CIAWI

PER/25/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

MA11222I

081211012 84


SM0480



135 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

41

1500000001535

RSUD CIAWI BOGOR


081211012 84

PER/20/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

42

1500000001535

RSUD CIAWI BOGOR


081211012 84

PER/25/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

43

1400000000442

RSUD KOTA BOGOR

JALAN RAYA SUMERU NO 120

DR TRIWANDHA ELAN

PER/ 14/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

44

1400000000442

RSUD KOTA BOGOR

JALAN RAYA SUMERU NO 120

DR TRIWANDHA ELAN

PER/08/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

45

1500000000230

RUMAH SAKIT PERTAMEDIKA SENTUL CITY

JL MH THAMRIN NO.1 SENTUL CITY BOGOR

29672977

KWEE LIANA KUMALA

PER/ 20/ 022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

46

1500000000230

RUMAH SAKIT PERTAMEDIKA SENTUL CITY

JL MH THAMRIN NO.1 SENTUL CITY BOGOR

29672977

KWEE LIANA KUMALA

PER/15/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

47

1400000000414

SALSABILLA MEDICAL CENTRE

JL KSR DADI KUSMAYADI RUKO LMC NO 70 CIKARET CIBINONG

87905768

DR WAHYU EKO W, SPOT

PER/06/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

48

1400000000414

SALSABILLA MEDICAL CENTRE

JL KSR DADI KUSMAYADI RUKO LMC NO 70 CIKARET CIBINONG

87905768

DR WAHYU EKO W, SPOT

PER/ 13/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KANTOR CABANG

NO

1

KODE PROVIDER

1400000000525

MA11222I

:

K03- KANTOR CABANG CIREBON

NAMA PROVIDER

KLINIK NAYAKA ERA HUSADA KOTA CIREBON

ALAMAT

JALAN VETERAN NO.13 KEBONBARU KOTA CIREBON

KODE POS

IKS TELEPON

PIMPINAN NO IKS

8300223


PER/004/122014



AWAL IKS 01/01/2015


SM0480



136 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1500000001053

KLINIK TRAUMA CENTRE AUREL

JALAN JANGGA-TRISI INDRAMAYU

DR. DEDEN

PER/006/042015

FFS

01/05/2015

30/04/2017

3

1500000001055

PKM ASTANAJAPURA

JL. RAYA KH WAHID HASYIM KP 45181

DINAS KESEHATAN KABUPATEN CIREBON

PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

4

1500000001076

PKM ASTANALANGGAR

JL. SILIWANGI DESA ASTANALANGGAR


PER/007/052015

FFS

01/05/2015

30/04/2017

5

1500000001077

PKM ASTAPADA

JL. KIYAI AGENG TAPA DESA ASTAPADA


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

6

1500000001078

PKM BABAKAN

JL. P.SUTAJAYA NO.40 DESA BABAKAN KP 45191


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

7

1500000001079

PKM BEBER

JL. P.SUDIRMAN NO.33 DESA BEBER

PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

8

1500000001080

PKM BUNDER

JL. BY PASS DESA BUNDER KP 45168

PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

9

1500000001081

PKM CIBOGO

JL. RAYA KH. ZAENAL ARIFIN DESA CIBOGO NO.12

PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

10

1500000001083

PKM CILEDUG

JL. ALUN-ALUN NO.20 KP 45188 DESA CILEDUG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

11

1500000001220

PKM CIPERNA

JL. DESA CIPERNA


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

12

1500000001221

PKM CIWARINGIN

JL. RAYA CIWARINGIN NO.35 DESA CIWARINGIN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

13

1500000001084

PKM DUKUPUNTANG

JL. IMAM BONJOL DESA CIKAHALANG KEC.DUKUPUNTANG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

MA11222I

832059

616028

661091

342358


SM0480



137 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

14

1500000001222

PKM GEBANG

JL. RAYA GEBANG KM 21 DESA GEBANG KULON

15

1500000001085

PKM GEGESIK

JL. RAYA GEGESIK NO. 20 DESA GEGESIK

16

1500000001086

PKM GEMBONGAN

17

1500000001087

18

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

JL. DESA GEMBONGAN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

PKM GEMPOL

JL. DESA GEMPOL


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

1500000001088

PKM GUNUNG JATI

JL. SUNAN GUNUNG JATI NO.56 DESA MERTASINGA


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

19

1500000001089

PKM JAGAPURA

JL. RAYA JAGAPURA GEGESIK KP 45164 DESA GEGESIK


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

20

1500000001091

PKM JEMARAS

JL. NYI MAS ENDANG GEULIS NO.88 DESA BANGODUA


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

21

1500000001092

PKM KALIBUNTU

JL. DI PANJAITAN KM 5.5 DESA KALIBUNTU KEC PABEDILAN

663363


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

22

1500000001093

PKM KALIWEDI

JL. GI GESANG NO. 1 DESA KALIWEDI LOR

357185


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

23

1500000001223

PKM KAMARANG

JL. JENDRAL A YANI NO.17 DESA KAMARANG KEC.GREGED

324025


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

24

1500000001094

PKM KARANGSARI

JL. KISABALANGKA NO.1 DESA KARANGSARI KEC.WERU


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

25

1500000001096

PKM KARANGSEMBUNG

JL. RAYA KARANGTENGAH NO. 2 KEC.KARANGSEMBUNG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

MA11222I

357788

635600


SM0480



138 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

26

1500000001097

PKM KEDATON

JL. SUNAN GUNUNGJATI DESA KAPETAKAN KEC.KAPETAKAN KP 45152

27

1500000001098

PKM KEDAWUNG

JL. H JUANDA NO.284 KEC.KEDAWUNG

28

1500000001099

PKM KEPUH

JL. KI AGENG TEPAK NO. 147 DESA KEPUH

29

1500000001100

PKM KLANGENAN

JL. OTTO ISKANDARDINATA KEC. KLAGENAN

30

1500000001102

PKM KUBANGDELEG

JL. RAYA KUBANGDELEG

31

1500000001103

PKM LOSARI

JL. H. DULNGALIM

32

1500000001105

PKM LURAH

JL. LURAH KEDUANAN NO. 1 KEC. PLUMBON

33

1500000001106

PKM MAYUNG

34

1500000001107

35

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

831604


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

244505


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

JL. KI GEDE MAYUNG NO. 36 DESA MAYUNG KEC. GUNUNGJATI 45151


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

PKM MUNDU

JL. RAYA LUWUNG DESA MUNDU


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

1500000001108

PKM PABUARAN

JL. P. SUTAJAYA NO. 192 DESA PABUARAN KP 451887


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

36

1500000001109

PKM PALIMANAN

JL. OTTO ISKANDARDIANATA NO. 7 PALIMANAN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

37

1500000001110

PKM PANGENAN

JL. RAYA CIREBON LOSARI KM 17 DESA ENDAR


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

MA11222I

487795

341363


SM0480



139 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

38

1500000001111

PKM PANGKALAN

JL. NYI GEDE CANGKRING NO. 6 DESA PANGKALAN KEC. PLERED


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

39

1500000001112

PKM PANGURAGAN

JL. NYI MAS GANDASAN DESA PANGKALAN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

40

1500000001114

PKM PASALEMAN

JL. RAYA PASALEMAN DESA PASALEMAN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

41

1500000001115

PKM PLERED

JL. OTTO ISKANDARDINATA NO, 40 DESA TEGALSARI


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

42

1500000001116

PKM PLUMBON

JL. RAYA PLUMBON KM 12 PLUMBON


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

43

1500000001117

PKM SEDONG

JL. KAPTEN MUSTOPA NO. 3 DESA SEDONG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

44

1500000001119

PKM SENDANG

JL. SYECH NURJATI NO. 351 KEL. SENDANG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

45

1500000001120

PKM SIDAMULYA

JL. SIDAMULYA NO. 375 DESA SIDAMULYA


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

46

1500000001121

PKM SINDANGJAWA

JL. NYI AGENG SERANG DESA SINDANG JAWA KEC. DUKUPUNTANG 456523209


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

47

1500000001122

PKM SINDANGLAUT

JL. LETJEN M.T. HARYONO DESA LEMAHABAG KULON


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

48

1500000001135

PKM SUMBER

JL. P. KEJAKSAN NO. 49 KEL. SUMBER


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

49

1500000001134

PKM SURANENGGALA

JL. SUNAN GUNUNGJATI DESA SURANENGGALA KEC. SURANENGGALA


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

MA11222I


SM0480



140 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

50

1500000001132

PKM SUSUKAN

JL. RAYA SUSUKAN NO. 27 DESA SUSUKAN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

51

1500000001131

PKM SUSUKAN LEBAK

JL. LETKOL H. M. YUSUF DESA SUSUKAN LEBAK


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

52

1500000001130

PKM TALUN

JL. P. CAKRABUANA DESA KECOMBERANAN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

53

1500000001129

PKM TEGALGUBUG

JL. LAPANGAM BOLA DESA TEGALGUBUG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

54

1500000001128

PKM TERSANA

JL. MAYJEN SUTOYO NO. 4 DESA TERSANA KEC. PABEDILAN


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

55

1500000001127

PKM WALED

JL. DEWI SARTIKA NO. 124 DESA WALED KOTA


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

56

1500000001126

PKM WANGUNHARJA

JL. MOH RAMDAN DESA WANGUNHARJA KEC. JAMBLANG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

57

1500000001125

PKM WARUROYOM

JL. WARUKAWUNG KEC. DEPOK


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

58

1500000001124

PKM WATUBELAH

JL. TANGKIL GEDE NO. 5 KEL. WATUBELAH


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

59

1500000001123

PKM WINONG

JL. RAYA WINONG BY PASS WINONG DESA WINONG


PER/007/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2017

60

0900000000017

RSTC BHAYANGKARA TK. IV INDRAMAYU

DS. KARIMUN LOSARANG

PER/002/003201 5

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

61

1500000000474

RSTC CIDERES

JL. RAYA CIDERES-KADIPATEN NO. 180, BOJONG CIDERES

PER/003/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

0233661003


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NO

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NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

31/12/2015

206330

PER/005/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

281043

PER/008/052015

FFS

01/05/2015

30/04/2017

PER/009/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

PER/004/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL KESAMBI NO.237

201861

63

1500000000618

RSTC GUNUNG JATI

JALAN KESAMBI NO.56 CIREBON

64

1500000001051

RSTC MAJALENGKA

JALAN KESEHATAN NO.77

65

0600000000001

RSTC MITRA PLUMBON

JL. RAYA PLUMBON KM. 11 PLUMBON

66

0900000000019

RSTC WIJAYA KUSUMAH

JL.MARTADINATA NO.172 KUNINGAN

KODE PROVIDER

AKHIR IKS

01/01/2015

RSTC CIREMAI

NO

AWAL IKS

RS.TRAUMA CENTRE

0900000000018

:

TIPE IKS

PER/001/012015

62

KANTOR CABANG

PIMPINAN

871565

TNI AD

YAYASAN WIJAYA KUSUMAH

K04- KANTOR CABANG TANGERANG CIKOKOL

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001928

KLINIK AFIQAH

JL. AMD CIBARENGKOK RT 01/04 DESA PEUSAR KEC. PANONGAN

29878013

DR. SAM MARGARETA

PER/50/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

2

1500000001206

KLINIK ALAM INDAH

JL KH HASYIM ASHARI NO 31 C TANGERANG

46708434

DRG SUGIHARTINI

PER/39/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

3

1500000000988

KLINIK BETH RAPHA AGAVE INSANI

JL. MAULANA HASANUDIN GANG AMPERA 2 NO 7-8 PORIS GAGA BATU CEPER

23693773

DR. SUSAN MARGARITA

PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

4

1500000000996

KLINIK BHAKTI MANDALA

JL. MOH. TOHA NO. 20C PABUARAN TUMPENG KEC. KARAWACI TANGERANG

5518867

DR. H. R. HANDAYA DIPANEGARA, M.KES, SPAK

PER/32/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1500000000985

KLINIK CITRA SEJAHTERA

JL. RAYA M. TOHA KM. 4 RT 02/02 KEL. PERIUK KEC. PERIUK

90329972

DR. DARSONO

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

6

1500000001016

KLINIK HANIFA MEDIKA

JL. RAYA RAJEG RT 02/01 RAJEG RAJAWALI DESA RAJEG KEC. RAJEG

95847058

DR. HADI FATHUR RAHMAN

PER/35/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

7

1500000001017

KLINIK KARAWACI MEDIKA

JL. IMAM BONJOL RAYA NO. 11 KEC. KARAWACI TANGERANG

55798985

AGUS JAELANI

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

8

1500000001244

KLINIK KOKITS MEDIKA

RUKO PLAZA PASAR BARU - BLOK B1 JL. MOH TOHA, PABUARAN TANGERANG

5520870

DR ALFI RAHMAH

PER/42/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

9

1500000001241

KLINIK KOSAMBI INSANI MEGAH

RUKO KOSAMBI MEGAH BLOK A/7 JL RAYA PRANCIS DADAP TANGERANG

5502676

YAYASAN PARTUHA

PER/43/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

10

1500000001712

KLINIK LESTARI ASIH

PERUMAHAN MEDANG LESTARI BLOK C4/C5 KEC. PAGEDANGAN KAB. TANGERANG

TITIK SURYATI

PER/46/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

11

1500000001205

KLINIK METTA MEDIKA

JL LIO BARU NO 1 (JL BOURAQ) BATU CEPER

DRG. MARETI MIHARDJA

PER/40/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001711

KLINIK MULIA ASIH

PERUM BINONG BLOK B5 NO. 14 KEC. CURUG KAB. TANGERANG

TITIK SURYATI

PER/47/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

13

1500000001283

KLINIK NURBAYAN

JL. METEOROLOGI, KOMP GURU MINDA KEL. TANAH TINGGI

DR. MOH. KHAERUMANSYAH

PER/44/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

14

1500000001015

KLINIK PEGA CITA

JL. RAYA PAKUHAJI KM. 5 PISANGAN KEPUH KEC. SEPATAN

118754

MIFTAHUL ULUM

PER/34/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

15

1500000000994

KLINIK PRADHANA

RUKO PANORAMA NIAGA NO. 16-17. JL. HALIM PERDANA KUSUMA, JURUMUDI BARU-TANGERANG

54380703

DRG. NI PUTU ARI SUANDEWI

PER/30/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

16

1500000000995

KLINIK PRASHANTI

RUKO PANORAMA CIBODAS A2/7 JL. KIANSANTANG KEL. SANGIANG JAYA KEC. PERIUK TANGERANG

5525365

DRG. NI PUTU ARI SUANDEWI

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I

5522007

15211


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1500000001204

KLINIK SABI MEDISTRA

JL DANAU SENTANI NO 1 PERUMNAS TANGERANG

5911830

DR SOLAIMAN BUDIMAN

PER/41/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

18

1500000000992

KLINIK SAMBA MEDIKA

JL. KH. MAULANA HASANUDIN NO. 39 KEL. PORIS GAGA KEC. BATU CEPER TANGERANG

83666559

DR. SEFI SAMBA TAKARIANTO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

19

1500000000999

KLINIK SUDIMARA BARAT

JL. RADEN FATAH NO.46 RT002/002 KEL. SUDIMARA BARAT KEC CILEDUG

7323207

LILLYANA LOKANANTA

PER/33/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

20

1500000001133

KLINIK SUMBER ASIH I

JL. RAYA SERANG KM 10,5 RT 001/001 DESA BITUNG JAYA KEC. CIKUPA

85145757

KUNADI SETIONO

PER/37/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

21

1500000001158

KLINIK SUMBER ASIH KELAPA DUA

JL. BOJONG NANGKA RAYA NO. 49 RT 05/01 MEDANG LESTARI,KEC. PAGEDANGAN

54213590

DR. MUWAH CHIDAH

PER/38/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

22

1500000001159

MAYAPADA HOSPITAL TANGERANG

JL. HONORIS RAYA KAV. 6, KOTA MODERN TANGERANG

55781888

DR. DEDI TEDJAKUSNADI, MARS

PER/26/052015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

23

1500000001159

MAYAPADA HOSPITAL TANGERANG

JL. HONORIS RAYA KAV. 6, KOTA MODERN TANGERANG

55781888

DR. DEDI TEDJAKUSNADI, MARS

PER/68/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1400000000650

RS BHAKTI ASIH

JL RADEN SALEH NO 10 KARANG TENGAH TANGERANG

7305662

YAYASAN BHAKTI ASIH

PER/67/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

25

1400000000652

RS. SARI ASIH CILEDUG

JL HOS COKROAMINOTO NO 38 CILEDUG

7333430

PT. SARI ASIH PUTRA MANDIRI, DICKY R H PAMUNGKAS

PER/17/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

1400000000652

RS. SARI ASIH CILEDUG

JL HOS COKROAMINOTO NO 38 CILEDUG

7333430


PER/66/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

27

1400000000651

RS. SARI ASIH KARAWACI

JL. IMAM BONJOL NO.38

5522794


PER/65/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

1400000000651

RS. SARI ASIH KARAWACI

JL. IMAM BONJOL NO.38

5522794


PER/18/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

29

1400000000655

RS. SILOAM HOSPITALS LIPPO VILLAGE

JL. SILOAM NO 6 LIPPO VILLAGE TANGERANG

5460055

PT. SILOAM INTERNATIONAL HOSPITALS

PER/16/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

30

1400000000655

RS. SILOAM HOSPITALS LIPPO VILLAGE

JL. SILOAM NO 6 LIPPO VILLAGE TANGERANG

5460055

PT. SILOAM INTERNATIONAL HOSPITALS

PER/69/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

31

1400000000653

RS. TINGKAT IV KESDAM JAYA DAAN MOGOT

JL DAAN MOGOT 59

5523551

TNI AD

PER/15/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

32

1500000000465

RS. USADA INSANI

JL. K.H HASYM ASHARI NO. 24 TANGERANG

55752575

PT. SURYA MITRA INSANI

PER/64/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

1500000000465

RS. USADA INSANI

JL. K.H HASYM ASHARI NO. 24 TANGERANG

55752575

PT. SURYA MITRA INSANI

PER/21/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

K05- KANTOR CABANG SERANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001294

BALAI BESAR LATIHAN KERJA INDUSTRI SERANG

JL RAYA PANDEGLANG KM 3 KOTA SERANG

200160

DEP TENAGA KERJA DAN TRANSMIGRASI

PER/12/042015

RS.TRAUMA CENTRE

01/04/2015

30/03/2016

2

1500000001319

BERTHA MEDIKA

JL. RAYA KARANG BOLONG NO. 23

081768386 47

DR HALILI SANUSI

PER/41/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

3

1500000000330

BP PERMATA HUSADA

JL LETJEND SUPRAPTO NO 45 CILEGON

WAWAN MULYANA

PER/07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1500000000330

BP PERMATA HUSADA

JL LETJEND SUPRAPTO NO 45 CILEGON

WAWAN MULYANA

PER/07/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1500000001276

KLINIK ADNAN MEDIKA

JL. RAYA SAWAHLUHUR KM 9 RT 01/01 KEL. SAWAHLUHUR, KASEMEN, KOTA SERANG

782537

MARDANI SJOFJAN

PER/17/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6

1500000001306

KLINIK AFINA ANYER

JL RAYA ANYER KP.GUDANG ARENG RT.15/03 NO.25 ANYER

087771253 335

DR.H.ACHMAD KHOMRUDIN

PER/37/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000001307

KLINIK AFINA CILEGON

JL RAMBUTAN NO.12 PAGEBANGAN

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1500000001274

KLINIK AL BAROKAH

JL RAYA PIPITAN - PETIR KM 3 WALANTAKA

087771652 567

MASITOH

PER/19/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1500000001298

KLINIK AL FURQON

JL. RAYA LABUAN KM.2 TAROGONG

081294600 11

DR. FURQON HAITAMI

PER/46/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000001474

KLINIK AMAL SEHAT

JL. AYIP USMAN KEBAHARAN DUKUH LOPANG RT 05/01

087871603 977

DR LENNY

PER/071/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

1500000001482

KLINIK AMANDA MEDIKA

JL RAYA LABUAN KM 128 KP. SAMBOYA KEC. ANYER

087771634 586

BD. SITI FATIYAH

PER/063/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

12

1500000001311

KLINIK AMBON ERA MEDIKA

KP. KAMAN SARI DS. LEUI LIMUS CIKANDE

087808192 103

IIS ISNAWATI

PER/33/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

13

1500000001313

KLINIK AMC (ASSA'ADAH MEDICAL CARE)

JL. RAYA PETIR KM. 16 DS. SUKAMENAK CIKEUSAL

085216679 543

DRG. IKA SARI MUSTIKA WATI

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

1500000001290

KLINIK ANDE KERTA SEJAHTERA

JALAN LANUD GORDA KM 68 DS JULANG KEC CIKANDE (KAWASAN PT PARKLAND WORLD INDONESIA 2)

081886360 4

TRIO BUDI AJTNIKO

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

15

1500000001277

KLINIK ANDRI MEDISTRA

JL RAYA CIRUAS-SERANG KM. 9 NO.9 KELURAHAN CITEREP CIRUAS

10820940

DR ANDRI HAVYATRA LUBIS

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1500000001293

KLINIK AR-ROHMAN

JL.PROF.DR.IR SOETAMI KM.10 KP.CURUG TUTUL RANGKASBITUNG

5282828

DR. GHOZI

PER/30/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1500000001303

KLINIK AVIVA

JL. RAYA BANTEN LAMA KM.5 SUKABE

087771372 393

HJ VENI

PER/40/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

18

1500000001299

KLINIK BHAKTI MULYA

JL. AHMAD YANI PASAR MALIMPIMG

087774495 520

AGUS KHOMEINI

PER/42/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

19

1500000001305

KLINIK BINA SEHAT

JL KH FATAH HASAN KOMP RUKO SUKSES 1 NO.1 CIJAWA

081896727 7

DR. A HASANUDIN

PER/38/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

20

1500000001297

KLINIK BONA MEDIKA SERANG

JL. RAYA SERANG RUKO SUKMAJAYA

081289414 44

DR RENITHA S TARBIN

PER/047/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

21

1500000001292

KLINIK BOUGENVILLE CIEKEK

JL. RAYA LABUAN KM 01 CIEKEK KEL. KARATON KEC. MAJASARI

081281552 16

ARIEF

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

22

1500000001475

KLINIK BUCHORI

JL. YUSUF MARTADILAGA NO. 36 BENGGALA

081218717 666

DR. BUCHORI

PER/070/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

23

1500000001472

KLINIK BUNDA MEDIKA

JL. RAYA JAKARTA KM.5 PARUNG

081291975 941

SUIBAH

PER/073/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

24

1500000001267

KLINIK DIFA

JL RAYA LABUAN KM 12 KP CIPUTRI DS ALASWANGI KEC MENES

085780622 081

DIDI MULYADI

PER/24/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

25

1500000001467

KLINIK DJASARI MEDIKA CURUG

KP.TINGGAR RT 03/02 DS.SUKALAKSANA KEC.CURUG

085254259 386

DRG. DIAN KIBLATI

PER/078/062015

RS.TRAUMA CENTRE

01/05/2016

31/05/2016

26

1500000001468

KLINIK FAIQOH MEDIKA

KP. PIPITAN RT 05/02

081118376 72

DR. FAIQOH

PER/077/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

27

1500000001455

KLINIK FATAHILLAH MEDIKA

JL. GRIYA SERDANG INDAH NO.229 SERDANG

087771301 685

YYS FATAHILAH

PER/060/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

28

1500000001321

KLINIK FIT MEDIKA

JL RAYA MERAK KM. 7 NO. 2 GROGOL

087771376 586

DR. DANANG

PER/051/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

29

1500000001273

KLINIK GANDI MEDIKA CIKANDE

JL. RAYA SERANG KM.69 KP.GORDA, ASEM RT.021/03 CIKANDE

082311921 355

MARLENA HARTATI

PER/20/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

30

1500000001270

KLINIK GANDI MEDIKA CILEGON

RUKO MEGA CILEGON JL.S.A. TIRTAYASA BLOK A-15 SIMPANG TIGA CILEGON

081234040 715

MARLENA HARTATI

PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

31

1500000001456

KLINIK GRIYA SEHAT

GRIYA CILEGON BLOK A1 NO. 2 SERDANG

087778553 595

DR. RETNO INDARINI

PER/059/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

32

1500000001322

KLINIK HIMMAH HUSADA KARYA UTAMA

JL. SUNAN KALIJAGA NO.235

DRG H HABIBULLAH

PER/049/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

33

1500000001471

KLINIK IKHLAS MEDIKA 2 (DUA)

JL. RAYA SERANG JAKARTA KM 4 PAKUPATAN

087771305 005

DR TETI ENDRIANI

PER/074/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

34

1500000001291

KLINIK INSAN PRIMA

RUKO CILEGON CITY SQUARE BLOK I-8

081281980 708

DRG LUSIANA ISKANDAR

PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

35

1500000001320

KLINIK INSANI

JL KOPO-CIKANDE KP. SEBE RT 16/05 DS RANCASUMUR

085610063 42

DR M. YUSTIANA

PER/050/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

36

1500000000331

KLINIK ISNA MEDIKA

JL RAYA MERAK KM 8 NO.1 LINK KESERANGAN RAWAARUM

573756

DR ISNAYATI

PER/08/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

37

1500000000331

KLINIK ISNA MEDIKA

JL RAYA MERAK KM 8 NO.1 LINK KESERANGAN RAWAARUM

573756

DR ISNAYATI

PER/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

1500000001473

KLINIK JANNAH 2

RUKO NIRWANA INDAH NO 8-9 KALODRAN

081112534 21

ADE

PER/072/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

39

1500000001479

KLINIK JASMINE SERANG

JL. TRIP JAMAKSARI NO.93 KALIGANDU

081316277 013

DR. TEJA RATRI

PER/066/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

40

1500000001301

KLINIK KAGUNGAN

JL KAGUNGAN NO 39 RT 02/07 LONTAR BARU

081295614 14

TITIK SUHAYATI

PER/44/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

41

1500000001310

KLINIK KHOIRUNNISA

JL. CIRUAS PERMAI BLOK D1 NO.7

081316206 264

IRA SYENTHIA DEWI

PER/34/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

42

1500000001271

KLINIK KIBIN MEDIKA

JL. RAYA SERANG-JAKARTA KM 71 KIBIN

087781512 539

TRIO BUDI JATNIKO

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

43

1500000001469

KLINIK KIMIA FARMA (A. YANI)

JL. JEND. A. YANI NO.57

081789707 5

PT KIMIA FARMA APOTEK

PER/076/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

44

1500000001470

KLINIK KIMIA FARMA (BENGGALA)

JL. YUSUF MARTADILAGA NO.144

081213450 55

PT KIMIA FARMA APOTEK

PER/075/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

45

1500000000254

KLINIK MEDIKA

JL JEND AHAMD YANI NO.56

209975

DR. DIANAHAN

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

46

1500000000254

KLINIK MEDIKA

JL JEND AHAMD YANI NO.56

209975

DR. DIANAHAN

PER/05/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

47

1500000001459

KLINIK MITRA MEDIKA

JL RAYA SERANG KM 39 RT 01/01 CIKANDE

081399090 915

DR. MUHAIMIN

PER/056/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

48

1500000000107

KLINIK MODERN MEDIKA CIKANDE

RUKO B6 KOMP MODERN INDUSTRI CIKANDE JL RAYA SERANG KM 68

400554

PT MODERN MEDIKA

PER/03/022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

49

1500000000107

KLINIK MODERN MEDIKA CIKANDE

RUKO B6 KOMP MODERN INDUSTRI CIKANDE JL RAYA SERANG KM 68

400554

PT MODERN MEDIKA

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

50

1500000001304

KLINIK MODERN MEDIKA KRAGILAN

JL. RAYA SERANG KM.15 RUKO D-9 KRAGILAN

081316372 239

PER/39/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

51

1500000001458

KLINIK MUCHIB'BAT

KP. KEDINGDING RT 01/02 DS KIBIN KEC KIBIN

081319531 937

BD. ELLA

PER/057/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

52

1500000001461

KLINIK MULTAZAM

JL. RAYA SERANG-JAKARTA KM.11 NO. 27 DS KESERANGAN KEC CIRUAS

087772826 045

DR. IFAD

PER/062/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

53

1500000001275

KLINIK MURASAKI MEDIKA

KOMP. PEJATEN MAS BLOK C NO.1

17063774

DRG. WARIH ANJARI

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

54

1500000001296

KLINIK NURHIKMAT

JL. FAMILY NO. 6

089888434 24

MAS ANDIKA CAKRA PRATAMA

PER/048/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

55

1500000001300

KLINIK PERMATA BUNDA

PERUMAHAN GRIYA PERMATA ASRI

ROHMAWATI

PER/45/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

56

1500000001476

KLINIK PERMATA NABILA

KOMPLEK PERMATA SERANG BLOK C NO 2 RT 01/17

087851215 003

SUHARTININGSIH

PER/069/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

57

1500000001312

KLINIK PISANG MAS MEDIKA

JL. RAYA KOPOMAJA

087772188 889

AEP SAEFULLOH

PER/32/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

58

1500000001266

KLINIK RAHAYU MEDIKA

JL H UMAR NO. 6 TEMU PUTIH

081886306 4

ANGGIT VIRGIAWAN

PER/25/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

59

1500000001460

KLINIK RAHMA MEDIKA

JL. PASAR BARU RT 01/04 WALURAN, ANYER

087871177 603

BD. MAMAH

PER/055/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

60

1500000001464

KLINIK SAHABAT SEHAT

JL RAYA TAKTAKAN 66

081316627 405

DR. RAHMAT F

PER/053/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

61

1500000001457

KLINIK SAKINAH

JL KECAMATAN NO 4 KP CIPACUNG KEC. CIKEUSAL

087771791 609

DR. ANIK SAKINAH

PER/058/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

62

1500000001462

KLINIK SAPTA MEDIKA

JL. RAYA SERANG KM. 71 KEDINDING KEC. KIBIN

081323209 449

DR. ELIS SULASTRI

PER/054/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

63

1500000001465

KLINIK SEHAT RABINZA

JL. HARDIWINANGUN 60 RUKO GARUDA BLOK BI ¿ BII MC. TIMUR

081296227 89

YENI SUTANTO

PER/052/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

64

1500000000255

KLINIK SERANG MEDIKA

JL RAYA SERANG CILEGON RUKO LEGOK SUKMAJAYA BLOK 5C NO. 1

223992

DR RINA NOVIA SP.AN

PER/06/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

65

1500000000255

KLINIK SERANG MEDIKA

JL RAYA SERANG CILEGON RUKO LEGOK SUKMAJAYA BLOK 5C NO. 1

223992

DR RINA NOVIA SP.AN

PER/06/032015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

66

1500000001302

KLINIK TANTI KIRANA

KP CIMINYAK KAB LEBAK

081311361 619

NURLAELAH

PER/43/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

67

1500000001481

KLINIK TUBAGUS MEDIKA

JL RAYA PALKA KM 1 (PALIMA) KEC. PABARUAN

085775665 451

ELLA

PER/064/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

68

1500000001308

KLINIK TUNAS MEDIKA

JL. RAYA PULO AMPEL KM. 17

081395549 666

H.MULYADI

PER/35/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

69

1500000001477

KLINIK UTAMA MEDIKA

JL. TB. SUWANDI PURI RAYA NO 17

089839689 88

DR. MUSLIH

PER/068/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

70

1500000001454

KLINIK UTAMA OTIKA BANTEN

JL. SERANG PANDEGLANG KM.11 BAROS

087771648 361

DR HUSEIN

PER/061/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

71

1500000001272

KLINIK WIJAYA MEDIKA

JL. GABUS SUKA MAJU KOPO SERANG

081316224 653

MARLENA HARTATI

PER/21/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

72

1500000001269

PRAKTEK DR. H. SRI EKA KURNIATI

JL. RAYA BOJONEGARA KP. BAKETOR DS MARGASARI KEC. BOJONEGARA

081381562 420

DR. H. SRI EKA KURNIATI

PER/23/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

73

1500000001478

PRAKTEK DR. ROSTIATI

JL. RAYA TAKTAKAN RT 01/12

081314868 269

DR. ROSTIATI

PER/067/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

74

1500000001480

PRAKTEK DR. SRI RAMAYANI

PERUM PURI ANGGREK BLOK.18/4

082110400 818

DR. SRI RAMAYANI

PER/065/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

75

1500000000329

RS HERMINA CIRUAS

JL RAYA SERANG JAKARTA KM 9 CIRUAS

280555

HERMINA HOSPITAL GROUP

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

76

1500000000329

RS HERMINA CIRUAS

JL RAYA SERANG JAKARTA KM 9 CIRUAS

280555

HERMINA HOSPITAL GROUP

PER/09/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

77

1500000000086

RS SARI ASIH SERANG

JL JEND SUDIRMAN NO 38 SERANG

220022

PT SARI ASIH ARIA CEMERLANG

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

78

1500000000086

RS SARI ASIH SERANG

JL JEND SUDIRMAN NO 38 SERANG

220022

PT SARI ASIH ARIA CEMERLANG

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

79

1500000001257

RSIA KURNIA CILEGON

JL. JOMBANG MASJID NO 04 CILEGON BANTEN

391161

PT. KURNIA SEJAHTERA

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

80

1400000000082

RSUD BANTEN

JL SYECH NAWAWI AL-BANTANI

8490911

PROVINSI BANTEN

PER/010/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

81

1500000000244

RSUD DR. ADJIDARMO

JL IKO DJATMIKO NO.1 RANGKASBITUNG

376433

RSUD ADJIDARMO

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

82

1500000000244

RSUD DR. ADJIDARMO

JL IKO DJATMIKO NO.1 RANGKASBITUNG

376433

RSUD ADJIDARMO

PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

83

1400000000320

RSUD SERANG

JL RUMAH SAKIT NO.1

42111

200528

KOTA SERANG

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

84

1400000000320

RSUD SERANG

JL RUMAH SAKIT NO.1

42111

200528

KOTA SERANG

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

85

1500000001256

RUMAH SAKIT KURNIA SERANG

JL. RAYA CILEGON SERANG KM 08 KRAMATWATU

232648

PT. KURNIA SEJAHTERA

PER/15/06/2015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

MA11222I

:

K06- KANTOR CABANG SUKABUMI


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

1500000001894

BLUD RS SEKARWANGI

JL. RAYA SILIWANGI NO.49 CIBADAK

2

1500000001937

KLINIK BEDAH DR.EDDY

JL. RA. KOSASIH NO. 218 CIAUL

3

1400000000244

KLINIK CICURUG MEDICAL CENTER

4

1400000000254

5

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/08/TC/0820 15

RS.TRAUMA CENTRE

01/08/2015

31/07/2016

244046

DR. EDDY YUSWARDI

PER/12/TC/0820 15

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

JL. RAYA SILIWANGI NO. 17 GG KORAMIL CICURUG KP NYANGKOWEK DS MEKARSARI

733767

DR. NASOKA RAMLI

PER/10/TC/0820 15

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

KLINIK GMC CIKEMBAR

JL PELABUHAN 2 KM 13 KP CIBODAS RT 03/04 DS KERTARAHARJA CIKEMBAR

324417

DR NASOKA RAMLI

PER/09/TC/0820 15

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

1400000000295

KLINIK PADJAJARAN ASSALAM

JL. RAYA CIKALONGKULON NO 61A

PER/17/TC/1220 15

RS.TRAUMA CENTRE

29/12/2015

31/08/2016

6

1400000000296

KLINIK PADJAJARAN SUKANAGARA

JL. RAYA SUKANAGARA KM 45

PER/18/TC/1220 15

RS.TRAUMA CENTRE

29/12/2015

31/08/2016

7

1400000000313

KLINIK PERMATA MEDICAL CENTER

JL. RAYA SILIWANGI NO. 38 PARUNGKUDA

531719

PER/19/TC/1220 15

RS.TRAUMA CENTRE

28/12/2015

31/08/2016

8

1500000001945

KLINIK RHAGASINDO

JL.RAYA SIMPANG CICANTAYAN NO.1

211068

PER/13/TC/0920 15

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

9

1400000000245

KLINIK SUKALARANG MEDICAL SERVICE

JL SUKABUMI-CIANJUR KP MANGLID RT 03/02 DS CIMANGKOK SUKALARANG

260227

PER/11/TC/0820 15

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

10

1500000000371

PKM BAROS

DS BAROS

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

11

1500000000369

PKM BENTENG

JL BENTENG KIDUL

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

12

1500000000156

PKM CIBADAK

JL RAYA SEGOG KM 11 KEC CIBADAK

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

MA11222I

43111

DR NASOKA RAMLI


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000360

PKM CIBEUREUM HILIR

JL CIBEUREUM HILIR

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

14

1500000000157

PKM CICANTAYAN

JL KH DAMANHURI KM 2 KEC CICANTAYAN

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

15

1500000000159

PKM CICURUG

JL SILIWANGI NO 113 KEC CICURUG

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

16

1500000000160

PKM CIDAHU

JL RAYA CIDAHU KM 7

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

17

1500000000152

PKM CIKEMBAR

JL PELABUHAN II KEC CIKEMBAR

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

18

1500000000362

PKM CIKUNDUL

JL PROKLAMASI

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

19

1500000000155

PKM CIPARI

JL RAYA CISAAT DS CISAAT KEC CICURUG

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

20

1500000000372

PKM CIPELANG

JL. JEND SUDIRMAN NO. 21

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

21

1500000000368

PKM GEDONG PANJANG

JL OTTO ISKANDARDINATA

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

22

1500000000162

PKM GUNUNG GURUH

JL PELABUHAN II PANYWEUAN DS SIRNA RESMI

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

23

1500000000161

PKM KADUDAMPIT

JL SITUGUNUNG KM 6 KEC KADUDAMPIT

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

24

1500000000361

PKM KARANG TENGAH

JL MERBABU NO 14 GN PUYUH

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1500000000158

PKM KARAWANG

JL SELABINTANA KM 5

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

26

1500000000370

PKM LEMBURSITU

JL. LEMBURSITU

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

27

1500000000367

PKM LIMUSNUNGGAL

JL PELDA SURYANTA

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

28

1500000000365

PKM NANGGELENG

JL PELDA SUYATNA

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

29

1500000000364

PKM PABUARAN

JL PABUARAN

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

30

1500000000163

PKM PARAKANSALAK

JL NEGLASARI NO 3 KEC PARAKANSALAK

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

31

1500000000149

PKM PARUNGKUDA

JL RAYA SILIWANGI NO 21 KEC PARUNGKUDA

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

32

1500000000150

PKM SEKARWANGI

JL SILIWANGI RW 017 KEC CIBADAK

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

33

1500000000358

PKM SELABATU

JL. SURYAKENCANA NO. 45

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

34

1500000000373

PKM SUKABUMI

JL RAYA CIAUL

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

35

1500000000363

PKM SUKAKARYA

JL TEGAL WANGI

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

36

1500000000154

PKM SUKALARANG

JL LEMBUR KM 7 KEC SUKALARANG

PER/02/TC/0220 15

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/03/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

224128

PER/02/TC/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL. RAYA CISAAT NO. 595

224128

PER/14/TC/12/20 15

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

RS BHAKTI MEDICARE

JL. RAYA SILIWANGI NO. 186 B, CICURUG, KAB SUKABUMI

731555

SUPRIADI SETIAWAN

PER/06/TC/0520 15

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

1400000000237

RS HERMINA SUKABUMI

JL RAYA SUKARAJA SUKABUMI

6252525

DR HASMORO, MHA, MM

PER/07/TC/0620 15

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

42

1500000000359

RS. AL MULK

JL LEMBURSITU

PER/04/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

43

1400000000522

RS. BHAYANGKARA TK III SETUKPA

JL. AMINTA AZMALI NO. 59

PER/11/TC/1220 14

RS.TRAUMA CENTRE

01/01/2015

31/12/2016

44

1400000000287

RSUD CIANJUR

JL. RUMAH SAKIT NO.1

PER/16/TC/1220 15

RS.TRAUMA CENTRE

29/12/2015

31/08/2016

45

1400000000671

RSUD CIMACAN

JL. RAYA CIMACAN NO. 17 CIPANAS

512465

PER/15/TC/1220 15

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

46

1400000000671

RSUD CIMACAN

JL. RAYA CIMACAN NO. 17 CIPANAS

512465

PER/13/TC/1220 14

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

47

1500000000060

RSUD PELABUHAN RATU

JL. A. YANI NO. 2 PELABUHAN RATU

PER/20/TC/1220 15

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

48

1500000000060

RSUD PELABUHAN RATU

JL. A. YANI NO. 2 PELABUHAN RATU

PER/01/TC/0120 15

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

37

1500000000366

PKM TIPAR

JL PEGADAIAN NO 1

38

1500000000059

RS BETHA MEDIKA

JL. RAYA CISAAT NO. 595

39

1500000000059

RS BETHA MEDIKA

40

1400000000196

41

MA11222I

229207


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

49

1500000000515

RSUD R. SYAMSUDIN SH

JL. RUMAH SAKIT NO. 1

PER/05/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

50

1500000000428

RUMKITBAN 03.08.01 PANGRANGO

JL. PGRI NO 8

PER/05/TC/0420 15

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

KANTOR CABANG

NO

KODE PROVIDER

:

K07- KANTOR CABANG TASIKMALAYA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001229

KLINIK PADJADJARAN KARANGPAWITAN

JL RAYA KARANGPAWITAN NO. 261

0435877

PT RS PADJADJARAN

PER/02/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

2

1500000000772

KLINIK PADJADJARAN LEUWIGOONG

JL RAYA LEUWIGOONG KP PASAR KIDUL

0435877

PT RS PADJADJARAN

PER/03/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

3

1500000000806

KLINIK PRATAMA PADJADJARAN WANARAJA

KP CIKOLE NO. 09 RT 003/004 DESA WANASARI KEC. WANARAJA

0435877

PT RS PADJADJARAN

PER/05/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

4

10223001

PUSKESMAS JAMANIS

JL. RAYA JAMANIS KEC. JAMANIS

PER/23/062015

RS.TRAUMA CENTRE

01/06/2015

30/05/2016

5

1400000000593

RUMAH SAKIT JASA KARTINI

JL OTTO ISKANDARDINATA NO. 15

PER/68/122015

RS.TRAUMA CENTRE

09/02/2016

31/12/2016

6

03800005

UPTD PUSKESMAS BANTAR

JL. GALUNGGUNG KEL. BANTARSARI KEC. BUNGURSARI

PER/55/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

10241501

UPTD PUSKESMAS BAYONGBONG

JL. SIMPANG BAYONGBONG NO. 183 DESA BAYONGBONG KEC. BAYONGBONG

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

331808

PT. KARSA ABDI HUSADA


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

1500000001218

UPTD PUSKESMAS BOJONGGAMBIR

JL. RAYA CIAWI NO. 43 DESA BOJONGGAMBIR KEC. BOJONGGAMBIR

PER/20/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

10242501

UPTD PUSKESMAS BUNGBULANG

JL. GARUDA-BUNGBULANG DESA BUNGBULANG KEC. BUNGBULANG

PER/35/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

10295301

UPTD PUSKESMAS BUNGURSARI

JL. BUNGURSARI KEL. BUNGURSARI KEC. BUNGURSARI

PER/51/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

10221001

UPTD PUSKESMAS CIAWI

JL. PANUMBANGAN CIAWI

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

12

10241201

UPTD PUSKESMAS CIBATU

JL. KI HAJAR DEWANTORO NO. 10 KEC. CIBATU

PER/27/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

13

10290801

UPTD PUSKESMAS CIBEUREUM

JL. LETKOL BASIR SURYA KEL. AWIPARI KEC. CIBEUREUM

PER/46/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

10221501

UPTD PUSKESMAS CIGALONTANG

JL. PERKANTORAN NO. 38 DESA CIGALONTANG KEC. CIGALONTANG

PER/62/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

15

10293701

UPTD PUSKESMAS CIGEUREUNG

JL. CIGEUREUNG KEL. SUKAMANAH KEC. CIPEDES

PER/48/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

10290301

UPTD PUSKESMAS CIHIDEUNG

JL PASEH KEL. TUGURAJA

PER/42/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

17

10241801

UPTD PUSKESMAS CIKAJANG

JL. RAYA CIKAJANG NO. 1 DESA CIKAJANG KEC. CIKAJANG

PER/32/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

18

10222501

UPTD PUSKESMAS CIKATOMAS

JL. RAYA RUMAH SAKIT NO. 17 DESA GUNUNGSARI KEC. CIKATOMAS

PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

19

10241601

UPTD PUSKESMAS CILAWU

JL. RAYA GARUT-TASIK KM. 18 DESA CILAWU KEC. CILAWU

PER/30/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

20

10294401

UPTD PUSKESMAS CILEMBANG

JL. BEBEDILAN NO. 5 KEL. CILEMBANG KEC. CIHIDEUNG

21

10220901

UPTD PUSKESMAS CINEAM

JL. YOGASWARA NO.112 DESA CINEAM KECAMATAN CINEAM

22

10220601

UPTD PUSKESMAS CISAYONG

23

10242701

24

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/49/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JL. CISAYONG DESA CISAYONG KEC. CISAYONG

PER/58/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

UPTD PUSKESMAS CISEWU

JL. PUSWABAKTI NO. 13 DESA CISEWU KEC. CISEWU

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10241701

UPTD PUSKESMAS CISURUPAN

JL. RAYA CISURUPAN NO. 27 DESA CISURUPAN KEC. CISURUPAN

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

25

10240503

UPTD PUSKESMAS DTP SUKARAJA

JL. RAYA WARUNG PEUTEUY DESA SUKARAJA KEC BANYURESMI

PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

26

10223901

UPTD PUSKESMAS GUNUNG TANJUNG

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

27

10290401

UPTD PUSKESMAS INDIHIANG

JL. PASAR INDIHIANG

PER/43/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

28

1500000001069

UPTD PUSKESMAS JAMANIS TASIKMALAYA

JL. RAYA JAMANIS KEC JAMANIS

PER/07/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

29

10224701

UPTD PUSKESMAS JATI WARAS

JL. RAYA CIKATOMAS DESA JATI WARAS KEC. JATI WARAS

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

30

10223101

UPTD PUSKESMAS KADIPATEN

JL. RAYA CIAWI GARUT DESA KADIPATEN KECAMATAN KADIPATEN

PER/09/06/2015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

31

10293601

UPTD PUSKESMAS KAHURIPAN

JL. SILIWANGI NO. 31 KEL. KAHURIPAN KEC. TAWANG

PER/38/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

380562

420560

957815


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

32

10290502

UPTD PUSKESMAS KARANG ANYAR

JL. TAMBIR KARANGANYAR RT 02/05 KEL. KARANG ANYAR KEC. KAWALU

PER/45/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

33

10220902

UPTD PUSKESMAS KARANGJAYA

JL. RAYA SIRNAJAYA DESA SIRNAJAYA

PER/59/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

34

10222101

UPTD PUSKESMAS KARANGNUNGGAL

L. RAYA KARANGNUNGGAL NO. 12 DESA KARANGNUNGGAL KEC KARANGNINGGAL

PER/21/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

35

10290501

UPTD PUSKESMAS KAWALU

JL. PERINTIS KEMERDEKAAN NO. 238 KEL. URUG KEC. KAWALU

PER/44/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

36

10240701

UPTD PUSKESMAS LELES

JL. PRAMUKA NO. 4 DESA LELES KEC. LELES

PER/25/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

37

10221401

UPTD PUSKESMAS LEUWISARI

JL. LEUWISARI NO. 25 DESA ARJASARI KEC. LEUWISARI

PER/61/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

38

10240901

UPTD PUSKESMAS LIMBANGAN

JL. RAYA LIMBANGAN TENGAH NO. 119 DESA LIMBANGAN TENGAH KEC. BL. LIMBANGAN

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

39

10293501

UPTD PUSKESMAS MANGKUBUMI

JL. CIGANTANG RAYA KEL. MANGKUBUMI

PER/47/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

40

10220701

UPTD PUSKESMAS MANONJAYA

JL. TANGSI NO. 6 KEC. MANONJAYA

PER/15/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

41

10221201

UPTD PUSKESMAS PAGEURAGEUNG

JL. RAYA PAGEURAGEUNG NO. 23 DESA PAGEURAGEUNG KEC. PAGEURAGEUNG

PER/60/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

42

1500000001230

UPTD PUSKESMAS PAMEUNGPEUK

JL CILAUTEUREUN NO. 212

PER/34/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

43

10295001

UPTD PUSKESMAS PANGLAYUNGAN

JL. DINDING PERUM BPR KEL. PANGLAYUNGAN KEC. CIPEDES

PER/50/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

44

03800001

UPTD PUSKESMAS PARAKAN NYASAG

JL. LEUWIDAHU KALER KEL. PARAKAN NYASAG KEC. INDIHIANG

PER/52/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

45

10294501

UPTD PUSKESMAS PURBARATU

JL. PURBARATU KEL SUKANAGARA KEC. PURBARATU

PER/39/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

46

10221101

UPTD PUSKESMAS RAJAPOLAH

JL. RAYA RAJAPOLAH DUSUN CIBARANI DESA MANGGUNJAYA

PER/17/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

47

1500000001225

UPTD PUSKESMAS SALOPA

JL. RAYA SALOPA NO. 226 DESA MANDALAHAYU KEC. SALOPA

PER/63/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

48

1500000001068

UPTD PUSKESMAS SALOPA

JL. RAYA SALOPA NO. 226

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

49

03800004

UPTD PUSKESMAS SAMBONGPARI

JL. MAYOR SL TOBING NO. 83 KEL. SAMBONGPARI KEC. MANGKUBUMI

PER/54/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

50

03800103

UPTD PUSKESMAS SANGKALI

KP. SANGKALI KEL. SANGKALI KEC. SANGKALI

PER/57/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

51

10223301

UPTD PUSKESMAS SARIWANGI

JL. SARIWANGI DESA JAYARATU DESA SARIWANGI

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

52

10241901

UPTD PUSKESMAS SINGAJAYA

L. RAYA SINGAJAYA DESA SINGAJAYA KEC. SINGAJAYA

PER/33/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

53

10221301

UPTD PUSKESMAS SINGAPARNA

JL. PANCAWARNA NO. 07 DESA SINGAPARNA KEC. SINGAPARNA

PER/08/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

54

03800003

UPTD PUSKESMAS SUKALAKSANA

JL. SUKALAKSANA KEL. SUKALAKSANA KEC. BUNGURSARI

PER/53/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

55

1500000001217

UPTD PUSKESMAS SUKARAJA

JL RAYA SUKARAJA-MANGUREJA DESA SUKAPURA KEC. SUKARAJA

PER/19/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

543414

545773


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

56

10292901

UPTD PUSKESMAS TAMANSARI

JL. TAMANSARI KEL. SUKAHURIP KEC. TAMANSARI

PER/37/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

57

1500000001227

UPTD PUSKESMAS TARAJU

JL. RAYA TARAJU NO. 149 RT 06/01 DESA TARAJU KEC. TARAJU

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

58

10240401

UPTD PUSKESMAS TAROGONG

JL. SUHERMAN NO 3 KEC. TAROGONG

PER/24/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

59

1500000001216

UPTD PUSKESMAS TAWANG

JL. RAA KURATANUNGINGRAT NO. 08 KEL. LENGKONGSARI

PER/40/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

60

1500000001216

UPTD PUSKESMAS TAWANG

JL. RAA KURATANUNGINGRAT NO. 08 KEL. LENGKONGSARI

PER/40/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

61

10221302

UPTD PUSKESMAS TINEUWATI

JL. RAYA SINGAPARNA DESA SINGAPARNA KEC. SINGAPARNA

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

62

0380012

UPTD PUSKESMAS URUG

JL. KANJENG SYEIKH ABD. MUHYI

PER/56/06/2015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

63

1500000001226

UPTD PUSKESMAS URUG

JL. KANJENG SYEIKH ABD. MUHYI

PER/56/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

64

10221701

UPTD PUSKESMASN TARAJU

JL. RAYA TARAJU NO. 149 RT 06/01 DESA TARAJU KEC. TARAJU

PER/15/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

65

10290201

UPTS PUSKESMAS CIPEDES

JL. MARTADINATA NO. 53 KEL CIPEDES

PER/41/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

66

10241301

UPTS PUSKESMAS MALANGBONG

JL. RAYA ALUN - ALUIN TIMUR NO. 5 DESA MALANGBONG KEC. MALANGBONG

PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

MA11222I

:

K09- KANTOR CABANG PURWAKARTA


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000758

KLINIK ANGKASA

JL RAYA KALIJATI SUBANG

TNI AU

PER/15/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

2

1500000001872

KLINIK ANNISA I

JL RAYA INDUSTRI KP MARACANG BABAKAN CIKAO

HJ NURUL HIDAYATI

PER/14/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

3

1500000000529

KLINIK AQMA CIKAMPEK

JL STASIUN NO 93 CIKAMPEK KARAWANG

310524

DOKTER IFRAN HAVSON HA, MARS

PER/15/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

4

1500000000528

KLINIK AQMA PLERED

JL. ANJUN NO 96 PLERED PURWAKARTA

270830

DR. IFRAN HAVSON, HA. MARS

PER/16/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

5

1500000000530

KLINIK AQMA PURWAKARTA

JL. IBRAHIM SINGADILAGA NO. 14 PURWAKARTA

200377

DR. IFRAN HAVSON

PER/17/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

6

1500000000542

KLINIK AQMA SUBANG

JL COMPRENG NO 25 PUSAKAJAYA SUBANG

540261

DR. IFRAN HAVSON HA, MARS

PER/18/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

7

1500000000696

KLINIK CAMPAKA

JL SADANG SUBANG DS CAMPAKASARI KEC CAMPAKA

212451

DR. NATALIA INDAWATI W

PER/12/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

8

1500000000769

KLINIK INSAN MADANI

JL RAYA CIBOGO KM 7 SUBANG

ASRIL ARSYAD DIPL RAD

PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

9

1400000000391

KLINIK MIRACLE

KOMP ANEKA JASA BLOK A2 NO. 9-10 KBI

351377

DR SUSANTO ONGKOWIDJAJA

PER/19/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

10

1500000000694

KLINIK MUNJUL

JL IPIK GANDAMANAH NO 206

212451

DR. NATALIA INDAWATY W

PER/11/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1500000000695

KLINIK MUNJUL JAYA 2

JL PRAMUKA NO 21 DS BUNDER KEC JATILUHUR

212451

DR. NATALIA INDAWATI W

PER/13/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

12

1500000001208

KLINIK PRAMA MEDIKA

DSN JURUTILU NO. 72 RT 72/6 KEC. CIASEM

DR PEPEN SOFYAN EFENDI

PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000001020

KLINIK RADIATIE

JL. RAYA CIKOPO RT 6/3 DS CIKOPO PURWAKARTA

DR PEPEN SOFIAN EFENDI

PER/ 21/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

1500000001022

KLINIK WALUYA

JL . RE MARTADINATA NO 60

DR . PEPEN SOFIAN EFENDI

PER/ 20 / 052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

15

1500000001021

KLINIK WIJAYA KUSUMAH

JL. RE MARTADINATA NO. 66

DR PEPEN SOFIAN EFENDI

PER/ 19/ 052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1400000000326

PUSKESMAS CIASEM

JL. RAYA CIASEM KEC CIASEM

081320777 941

DINAS KESEHATAN KAB SUBANG

PER/09/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

17

1400000000328

PUSKESMAS CIBOGO

JL RAYA CINANGSI KEC CIBOGO

081218499 93


PER/10/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

18

1400000000329

PUSKESMAS CIPEUNDEUY SUBANG

JL.RAYA PABUARAN CIPEUNDUY

DINAS KESEHATAN

PER/11/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

19

1400000000330

PUSKESMAS PABUARAN

JL RAYA PASAR SENEN PABUARAN KEC PABUARAN

081320284 083

DINAS KESEHATAN

PER/12/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

20

PER/ 09/022015

PUSKESMAS RAWALELE

JL RAYA SUBANG KALIJATI KEC DAWUAN

082216333 567


PER/09/022015

RS.TRAUMA CENTRE

01/02/2015

01/01/2016

21

1500000000404

RS BHAKTI HUSADA II PURWAKARTA

JL. RAYA SADANG -SUBANG KM 5 RT 1/1 DS CIKUMPAY KEC. CAMPAKA

8225344

PER/11/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

22

1500000000759

RS PANGKALAN TNI AU SURYADARMA

JL RAYA KALIJATI SUBANG

TNI AU SURYADARMA

PER/16/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

23

1300000000035

RS. MH THAMRIN PURWAKARTA

JL. RAYA BUNGURSARI NO. 36 SADANG

8222222

DR.H. KEMAL MUHAMAD, MMR.,M.KES,AIFO

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

1300000000035

RS. MH THAMRIN PURWAKARTA

JL. RAYA BUNGURSARI NO. 36 SADANG

8222222

DR.H. KEMAL MUHAMAD, MMR.,M.KES,AIFO

PER/01/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

25

1400000000434

RSUD BAYU ASIH

JL VETERAN NO 39

26

1400000000441

RSUD KELAS B KABUPATEN SUBANG

JL BIGJEN KATAMSO NO 37

27

1500000001876

RUMAH SAKIT KHUSUS BEDAH RAMAHADI

JL RAYA SADANG-SUBANG DESA CIWANGI-BUNGURSARI PURWAKARTA

202136

28

1500000000405

SILOAM HOSPITALS PURWAKARTA

JL. BUNGURSARI NO 1

219168

29

1400000000401

YAYASAN AQMA

JL STASIUN NO 93 CIKAMPEK

KANTOR CABANG

NO

KODE PROVIDER

:

PIMPINAN

DINAS KESEHATAN KABUPATEN SUBANG

PT. BERLIAN CAHAYA INDAH

TIPE IKS

AWAL IKS

AKHIR IKS

PER/20/102015

RS.TRAUMA CENTRE

21/01/2016

31/10/2016

PER/14/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

PER/18/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/ 10/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PER/13/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

K10- KANTOR CABANG KARAWANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001517

KLINIK GRAHA MEDIS CILAMAYA

JL RAYA CILAMAYA DESA CILAMAYA WETAN KAB KARAWANG

340202

DR H. SUNUHARDO EP, M.KES

PER/11/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

2

1500000001517

KLINIK GRAHA MEDIS CILAMAYA

JL RAYA CILAMAYA DESA CILAMAYA WETAN KAB KARAWANG

340202

DR H. SUNUHARDO EP, M.KES

PER/35/062015

RS.TRAUMA CENTRE

19/06/2015

31/12/2015

3

1500000000409

KLINIK BHAKTI MEDIKA

JL AHMAD YANI NO 100 DAWUAN CIKAMPEK

8862936

MUHAMMAD SAFI'I MA'ARIF ,SE

PER/17/032015

RS.TRAUMA CENTRE

31/03/2015

31/12/2015

4

1500000000409

KLINIK BHAKTI MEDIKA

JL AHMAD YANI NO 100 DAWUAN CIKAMPEK

8862936

MUHAMMAD SAFI'I MA'ARIF ,SE

PER/15/2016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1500000000847

KLINIK BINA MEDIKA

JL RAYA TELUK JAMBE NO 5 DESA TELUK JAMBE

641968

SUDIARTO (08121918055)

PER/30/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

6

1500000000847

KLINIK BINA MEDIKA

JL RAYA TELUK JAMBE NO 5 DESA TELUK JAMBE

641968

SUDIARTO (08121918055)

PER/16/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

7

7-1372189411

KLINIK CURUG RAHAYU

KP KARAJAN 2 DS CURUG KEC KLARI

MARANTINO LUMMUSA

PER/24/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

8

1500000000846

KLINIK GEMPOL

JL RANGGA GEDE NO 29 GEMPOL KEL TANJUNG PURA KEC KARAWANG BARAT

02678453903

SUDIARTO (08121918055)

PER/32/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

9

1500000000846

KLINIK GEMPOL

JL RANGGA GEDE NO 29 GEMPOL KEL TANJUNG PURA KEC KARAWANG BARAT

02678453903

SUDIARTO (08121918055)

PER/17/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

10

1500000001515

KLINIK GRAHA MEDIS CIKAMPEK

JL A. YANI NO 51 DAWUAN TIMUR

310101

DR. HJ. DYAH PERMATA S.M.KES

PER/33/062015

RS.TRAUMA CENTRE

19/06/2015

31/12/2015

11

1500000001515

KLINIK GRAHA MEDIS CIKAMPEK

JL A. YANI NO 51 DAWUAN TIMUR

310101

DR. HJ. DYAH PERMATA S.M.KES

PER/12/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

12

1500000001516

KLINIK GRAHA MEDIS KOPEL

JL RAYA KLARI DS KLAPANUNGGAL RT 26/07 GINTUNG KERTA KLARI

DR H DYAH PERMATA SURYARINI M.KES

PER/34/062015

RS.TRAUMA CENTRE

19/06/2015

31/12/2015

13

1500000001516

KLINIK GRAHA MEDIS KOPEL

JL RAYA KLARI DS KLAPANUNGGAL RT 26/07 GINTUNG KERTA KLARI

DR H DYAH PERMATA SURYARINI M.KES

PER/13/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

14

1500000001518

KLINIK GRAHA MEDIS KOSAMBI

JL RAYA KOSAMBI NO 23 DESA DUREN KLARI

435527

DR.H. SUNUHARDO EP, M.KES

PER/14/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

15

1500000001518

KLINIK GRAHA MEDIS KOSAMBI

JL RAYA KOSAMBI NO 23 DESA DUREN KLARI

435527

DR.H. SUNUHARDO EP, M.KES

PER/36/062015

RS.TRAUMA CENTRE

19/06/2015

31/12/2015

16

1500000000843

KLINIK MITRA GEMPOL

JL PROKLAMASI NO 15 KW 8 RT 003/005 KEL TUNGGAK JATI KEC KARAWANG BARAT

483749

SUDIARTO (08121918055)

PER/31/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

MA11222I

41371


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1500000000843

KLINIK MITRA GEMPOL

JL PROKLAMASI NO 15 KW 8 RT 003/005 KEL TUNGGAK JATI KEC KARAWANG BARAT

483749

SUDIARTO (08121918055)

PER/18/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

18

1500000000840

KLINIK MITRA SEHAT

JL KOSAMBI CURUG NO 28 DESA DUREN KEC KLARI

433930

SUDIARTO

PER/28/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

19

01019

KLINIK MITRA SEHAT

JL. RAYA KOSAMBI CURUG NO 28 KARAWANG

433930

DR. YUNITA PUSPITASARI

PER/19/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

20

1500000000463

KLINIK NAYAKA

JL TUPAREV NO 334 B DAN C KARAWANG

418430

PENDI SUPENSI

PER/20/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

21

1500000000463

KLINIK NAYAKA

JL TUPAREV NO 334 B DAN C KARAWANG

418430

PENDI SUPENSI

PER/19/032015

RS.TRAUMA CENTRE

31/03/2015

31/12/2015

22

1500000000848

KLINIK PURWA MEDIKA

JL RAYA TAMELANG NO 53 DESA MEKARJAYA KEC. PURWASARI

433653

SUDIARTO (08121918055)

PER/21/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

23

1500000000848

KLINIK PURWA MEDIKA

JL RAYA TAMELANG NO 53 DESA MEKARJAYA KEC. PURWASARI

433653

SUDIARTO (08121918055)

PER/29/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

24

1500000001948

KLINIK SATRIA MEKAR

JL PANGKALAN LOJI DESA TAMAN MEKAR KEC. PANGKALAN

41311

085624943 888

YAYAT SALEH

PER/25/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

25

1500000001948

KLINIK SATRIA MEKAR

JL PANGKALAN LOJI DESA TAMAN MEKAR KEC. PANGKALAN

41311

085624943 888

YAYAT SALEH

PER/44/092015

RS.TRAUMA CENTRE

21/09/2015

31/12/2015

26

1500000000407

KLINIK YAKESTI

JL RAYA KLARI RT 01/02 GINTUNG KERTA KLARI KARAWANG

432416

MUHAMMAD SAFEI'I MA'ARIF

PER/16/032015

RS.TRAUMA CENTRE

31/03/2015

31/12/2015

27

1500000000407

KLINIK YAKESTI

JL RAYA KLARI RT 01/02 GINTUNG KERTA KLARI KARAWANG

432416

MUHAMMAD SAFEI'I MA'ARIF

PER/22/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

28

1500000001714

KLINIK YASMIN

JL IR H JUANDA KM2 KOTA BARU RT 02/05

SAFRINA DEWI

PER/38/062015

RS.TRAUMA CENTRE

29/06/2015

31/12/2015

MA11222I

41311


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

SAFRINA DEWI

PER/23/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

8452555

NY ANGELIAQUE ARYANTO

PER/27/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

8452555

NY ANGELIAQUE ARYANTO

PER/09/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

41311

026740181 8

DR WHISNU SANTOSO

PER/01/012016

RS.TRAUMA CENTRE

06/01/2016

31/12/2016

JL ARTERI TOL KARAWANG BARAT KEC TELUK JAMBE

41312

414245

HAJI GANGGA ENDANG HERMAWAN

PER/26/052015

RS.TRAUMA CENTRE

18/05/2015

31/12/2015

RS CITO

JL. ARTERI TOL KARAWANG BARAT

41312

HAJI GANGGA ENDANG

PER/03/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

1400000000368

RS CITRA SARI HUSADA

JL RAYA KOSAMBI TELAGASARI KM 3 KLARI

437507

ADE RELAWATI

PER/05/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

36

1400000000368

RS CITRA SARI HUSADA

JL RAYA KOSAMBI TELAGASARI KM 3 KLARI

437507

ADE RELAWATI

PER/22/04/2015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

37

1500000001708

RS DELIMA ASIH SISMA MEDIKA

JL WIRASABA NO 54 JOHAR KEC KARAWANG TIMUR

41311

403073

PT DELIMA SISMA MEDIKA

PER/37/062015

RS.TRAUMA CENTRE

29/06/2015

31/12/2015

38

1500000001708

RS DELIMA ASIH SISMA MEDIKA

JL WIRASABA NO 54 JOHAR KEC KARAWANG TIMUR

41311

403073

PT DELIMA SISMA MEDIKA

PER/04/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

39

1400000000349

RS ISLAM KARAWANG

JL. PANGKAL PERJUANGAN KM. 2

PER/06/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

40

1400000000349

RS ISLAM KARAWANG

JL. PANGKAL PERJUANGAN KM. 2

PER/21/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

29

1500000001714

KLINIK YASMIN

JL IR H JUANDA KM2 KOTA BARU RT 02/05

30

1500000000849

LIRA MEDIKA

JL SYECH QURO NO 14 PALUMBONSARI

31

1500000000849

LIRA MEDIKA

JL SYECH QURO NO 14 PALUMBONSARI

32

7-1272337870

RS BAYU KARTA

JL. KERTABUMI NO 44 KARAWANG

33

1500000000814

RS CITO

34

7-1122449393

35

MA11222I

41311


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

41

1500000000408

RS IZZA

JL RAYA CISELANG DESA CIKAMPEK UTARA KECAMATAN KOTA BARU

8386830

DR MED H LUQMAN ADJI SAPTOGINO, SP RAD (K) DAN SP KN

PER/07/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

42

1500000000408

RS IZZA

JL RAYA CISELANG DESA CIKAMPEK UTARA KECAMATAN KOTA BARU

8386830

DR MED H LUQMAN ADJI SAPTOGINO, SP RAD (K) DAN SP KN

PER/15/032015

RS.TRAUMA CENTRE

31/03/2015

31/12/2015

43

1400000000348

RS KARYA HUSADA

JL. JEND. AHMAD YANI NO. 98 CIKAMPEK KARAWANG

PER/20/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

44

1400000000348

RS KARYA HUSADA

JL. JEND. AHMAD YANI NO. 98 CIKAMPEK KARAWANG

PER/08/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

45

1400000000347

RS PURI ASIH JATISARI

JL. RAYA JATISARI NO. 3 MEKARSARI JATISARI

DR AKID

PER/23/04/2015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

46

1400000000347

RS PURI ASIH JATISARI

JL. RAYA JATISARI NO. 3 MEKARSARI JATISARI

DR AKID

PER/10/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

47

7-140398203

RS TC HERMINA GRAND WISATA

JL FESTIVAL BOULEVARD GRAND WISATA LAMBANG SARI TAMBUN SELATAN BEKASI

DR. HASMORO

PER/55/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2016

48

06823

RSU DELIMA ASIH SISMA MEDIKA

JL WIRASABA NO 54 JOHAR

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

49

7-1277095197

RUMAH SAKIT FIKRI MEDIKA

JL. RAYA KOSAMBI TELAGASARI KM 3

PER/02/012015

RS.TRAUMA CENTRE

05/01/2016

30/06/2016

KANTOR CABANG

MA11222I

:

17510

82651212

403073

41314

H SAEPUDIN

K11- KANTOR CABANG CIMAHI


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

1

1500000001616

KLINIK CAHAYA BUNDA

JL PASIR KEMIRI BLOK A NO. 2 RT01 RW18 DS CIGUGUR GIRANG KEC PARONGPONG

2

1500000000232

KLINIK NAYAKA ERA HUSADA

JL. JEND. H. AMIR MACHMUD NO 477 CIBABAT CIMAHI

6640384

3

1500000000679


PERUM BATUJAJAR REGENCY R6 JL RAYA BATUJAJAR KAB BANDUNG BARAT

085102712 227

4

1500000000682


KP RANCAKUDA RT 001 RW 003 DESA CITAPEN KEC CIHAMPELAS KAB BANDUNG BARAT

085320241 143

5

1500000000683


JL. CIHALIWUNG NO 181/10 A RT 03/10 KERTAMULYA KEC PADALARANG KAB BANDUNG BARAT

082318663 331

6

1500000000678

KLINIK NAYAKA HUSADA03

JL. BAROS RT 001 RW 004 KEL LEUWIGAJAH KEC CIMAHI SELATAN

085100792 646

7

1500000001615

KLINIK PADJADJARAN RENDE

JL RAYA RENDE KEC CIKALONGWETAN

8

1500000000684

KLINIK PRATAMA ALIKHLAS 1

JL. LETKOL GA MANULANG NO 141 RT 02 RW 02 PADALARANG

9

1500000000685

KLINIK PRATAMA ALIKHLAS 3

JL. JEND AMIR MACHMUD NO 95 KOMP BUMI INDAH H-7 RT 006 RW 020 KEL CIBEUREUM KEC CIMAHI SELATAN

10

1500000001930

KLINIK PRATAMA RAHARDJA

JL RAYA PURWAKARTA NO. 332 TAGOG APU PADALARANG

11

1500000000233

KLINIK PRATAMA SEHAT BUDI LUHUR

12

1500000000234


MA11222I

PIMPINAN TIPE IKS

AWAL IKS

AKHIR IKS

PER/69/062015

RS.TRAUMA CENTRE

01/07/2015

01/07/2016

PT NAYAKA ERA HUSADA CABANG CIMAHI

PER/02/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

PT NAYAKA ERA HUSADA CABANG CIMAHI

PER/59/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/61/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/62/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/60/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DR WENDY FREELY NUGRAHA

PER/67/062015

RS.TRAUMA CENTRE

01/07/2015

01/07/2016

6806575

ANNEU FEURYTA

PER/63/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

6123955

ANNEU FEURYTA

PER/64/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

081321355 812

ENDANG HARTATI AM.KEP

PER/72/082015

RS.TRAUMA CENTRE

03/08/2015

30/06/2016

JL. KERKOF NO 32 CIMAHI SELATAN

6674146

KLINIK SEHAT BUDI LUHUR

PER/03/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

JL. RAYA CIBURUY NO 684 PADALARANG

6806125


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

40391

PT NAYAKA ERA HUSADA CABANG CIMAHI PT NAYAKA ERA HUSADA CABANG CIMAHIA CABANG CIMAHI PT NAYAKA ERA HUSADA CABANG CIMAHI


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1100000000027

RS DUSTIRA

JL. RUMAH SAKIT NO 1 CIMAHI

6633967

PER/70/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

14

1400000000224

RSU AVISENA

JL. MELONG NO 170 BLOK CIKENDAL

6000830

PER/71/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

15

1400000000225

RSUD CIBABAT CIMAHI

JL. AMIR MAHMUD NO 140 CIMAHI

6652025

PER/68/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

K12- KANTOR CABANG SUMEDANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000508

BALAI PENGOBATAN ELTIGIP

JL. PARAKAN MUNCANG , SINDANGPAKUAN, CIMANGGUNG

082116018 157

ENDANG WALSUM

PER/21/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

2

1500000000481

KLINIK AFIATI BOJONGSOANG

JL. RAYA BOJONGSOANG NO. 98

95547889

DR. AMETA PRIMASARI, DRG, MKES, MDSC

PER/08/032015

FFS

01/03/2015

31/12/2015

3

1500000000491

KLINIK AFIATI CICALENGKA

JL. RAYA BARAT NO.157, CICALENGKA

91192060

DR.AMETA PRIMASARI, DRG, MKES, MDSC.

PER/09/032015

FFS

01/03/2015

31/12/2015

4

1500000000490

KLINIK AFIATI SOREANG

JL. RAYA SOREANG BANJARAN NO.298

5892159

DR. AMETA PRIMASARI, DRG, MKES, MDSC

PER/10/032015

FFS

01/03/2015

31/12/2015

5

1500000000499

KLINIK CAHAYA QALBU

JL. RAYA LASWI NO.480 CIKOPO, CIPARAY

85963355

DR HERVI NURYANIA MEGA REZA

PER/15/032015

FFS

01/03/2015

31/12/2015

6

1500000000485

KLINIK IBNU SINA

JL. RANCAEKEK - MAJALAYA SOLOKANJERUK

081395373 337

DR.H AYI KURNIAWAN

PER/19/032015

FFS

01/03/2015

31/12/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

1500000000484

KLINIK KELUARGA SEHAT

JL GADING TUTUKA 1 BLOK S 1 NO 5 SOREANG

85873559

BAMBANG TRIYONO

PER/18/032015

FFS

01/03/2015

31/12/2015

8

1500000000521

KLINIK KESEHATAN KERJA (BKKM)

JL. RAYA RANCAEKEK KM.27 NO.612, NANJUNGMEKAR, RANCAEKEK

081320009 434

PEMERINTAH PROPINSI

PER/14/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

9

1500000000506

KLINIK MARLINA

JL. MANIRANCAN NO.226 B, DS. MAJASETRA, MAJALAYA

085722699 969

HJ. ERLIN TATI

PER/11/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

10

1500000000482

KLINIK MEDIKA PRATAMA II

JL. RAYA BANDUNG GARUT NO.24 BOJONGLOA, RANCAEKEK

7537511

LULU FOTUANA

PER/12/032015

FFS

01/03/2015

31/12/2015

11

1500000000483

KLINIK MEDIKA PRATAMA III

JL. RAYA BANJARAN NO.564, BOJONGMANGGU, PAMEUNGPEUK

7537511

LULU FOTUANA

PER/13/032015

FFS

01/03/2015

31/12/2015

12

1500000000489


JL. MOH. TOHA PALASARI , DAYEUH KOLOT

085106398 668

PT. NAYAKA ERA HUSADA

PER/04/032015

FFS

01/03/2015

31/12/2015

13

1500000000488


JL. BALEKAMBANG SUKAMAJU MAJALAYA

082318663 334


PER/05/032015

FFS

01/03/2015

31/12/2015

14

1500000000487


KP. KAWUNGSARI 324 BALEENDAH

082318663 331


PER/06/032015

REIMBURSE

02/03/2015

31/12/2015

15

1500000000487


KP. KAWUNGSARI 324 BALEENDAH

082318663 331


PER/06/032015

FFS

02/03/2015

31/12/2015

16

1500000000511

KLINIK PADJADJARAN

JL. RAYA BANDUNG SUMEDANG KM.21, JATINANGOR

083820435 877

DR. REAGEN VINCENT OKTAVIAN MARCELINO PANTOUW

PER/22/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

17

1500000000486

KLINIK PRATAMA DR.E. ATJEP LESMANA

JL. RAYA DAYEUHKOLOT NO.335 CITEUREUP, DAYEUHKOLOT

85963355

DR. E ATJEP LESMANA

PER/16/032015

FFS

01/03/2015

31/12/2015

18

1500000000492

KLINIK RATNASARI SEHAT

JL. SOREANG BANJARAN, CILUNCAT, CANGKUANG

081206052 93

DR. RATNA SARIHARYANTI

PER/17/032015

FFS

01/03/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

19

1500000000510

KLINIK WASILAH SEHAT

JL. LASWI CIPARAY NO.817, CIPARAY

5950916

DR. H. KOSIM. SYARIF MKM

PER/07/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

20

0900000000038

RS AMC (TRAUMA CENTRE)

JL. RAYA CILEUNYI RANCAEKEK

7781630

PT. ANISSA EKA UTAMA

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

21

1300000000042

RS BHAYANGKARA BANDUNG (TRAUMA CENTER)

5229544

POLDA JABAR

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1500000000135

RSU PAKUWON

JL RD DEWI SARTIKA NO.17

210931

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

23

1500000000135

RSU PAKUWON

JL RD DEWI SARTIKA NO.17

210931

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

1500000000505

RSUD KABUPATEN SUMEDANG

JL. P GEUSAN ULUN NO.41

7217744

PEMDA JAWA BARAT

PER/20/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

25

1500000001175

RUMAH SAKIT UMUM BINA SEHAT

JL. RAYA DAYEUH KOLOT NO.325

5207963

DR.H GUNTUR ALAMSYAH, MARS

PER/23/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

K13- KANTOR CABANG TANGERANG CIKUPA

NAMA PROVIDER

ALAMAT

1

1400000000556

CIPUTRA HOSPITAL

JL CITRA RAYA BOULEVARD BLOK V.00/08 SEK. 3.4 TANGERANG

2

1500000001507

KLINIK BHAKTI MULYA KRONJO

JL.RAYA KRONJO NO.6 DESA PASILIAN KRONJO

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

59405555

TIPE IKS

AWAL IKS

AKHIR IKS

CIPUTRA

PKS/26/122015

RS.TRAUMA CENTRE

30/12/2015

31/12/2016

DR.A GHOFIR

PER/ PKS/ 14 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

1500000001507

KLINIK BHAKTI MULYA KRONJO

JL.RAYA KRONJO NO.6 DESA PASILIAN KRONJO

DR.A GHOFIR

PKS/31/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

4

1500000001506

KLINIK BKKM BANTEN

JL RAYA SERANG KM.31 SUMUR BANDUNG JAYANTI

DR.H.A DRAJAT A.P MKES

PER/ PKS/ 16 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

5

1500000001506

KLINIK BKKM BANTEN

JL RAYA SERANG KM.31 SUMUR BANDUNG JAYANTI

DR.H.A DRAJAT A.P MKES

PKS/33/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

6

1500000001513

KLINIK CITRA INSANI

MARDI GRAS RUKO KF02/05 CITRA RAYA CIKUPA

DR SABRI

PKS/32/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

7

1500000001513

KLINIK CITRA INSANI

MARDI GRAS RUKO KF02/05 CITRA RAYA CIKUPA

DR SABRI

PER/ PKS/ 15 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

8

1500000001314

KLINIK MILENIA SEJAHTERA 1 TIGARAKSA

JL MILENIUM RAYA 1A /A11 18-19 TIGARAKSA

29006869

PER / TC / 11 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

9

1500000001314

KLINIK MILENIA SEJAHTERA 1 TIGARAKSA

JL MILENIUM RAYA 1A /A11 18-19 TIGARAKSA

29006869

PKS/28/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

10

1500000001309

KLINIK MILENIA SEJAHTERA 2 BALARAJA

RUKO ULITMATE BLOK A1-2 JL RAYA SERANG KM24 BALARAJA

29015571

PKS/29/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

11

1500000001309

KLINIK MILENIA SEJAHTERA 2 BALARAJA

RUKO ULITMATE BLOK A1-2 JL RAYA SERANG KM24 BALARAJA

29015571

PER / TC / 12 /062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001512

KLINIK MULYA RAHAYU

JL. PLP LEGOK ASEM NO.124 LEGOK

HJ SRI LIS RAHAYU

PKS/30/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

13

1500000001512

KLINIK MULYA RAHAYU

JL. PLP LEGOK ASEM NO.124 LEGOK

HJ SRI LIS RAHAYU

PKS/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

14

1500000001508

KLINIK PRIMA MEDIKA

JL. RAYA SERANG KM.14,8 KOMP RUKO B/16 CIKUPA

MUSAFAH

PER/ PKS/ 17 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

15

1500000001508

KLINIK PRIMA MEDIKA

JL. RAYA SERANG KM.14,8 KOMP RUKO B/16 CIKUPA

MUSAFAH

PKS/34/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

16

1500000001510

KLINIK PRIMA SENTUL

JL. RAYA SERANG KM.24 A/11 SENTUL BALARAJA

MUSAFAH

PER/ PKS/ 18 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

17

1500000001510

KLINIK PRIMA SENTUL

JL. RAYA SERANG KM.24 A/11 SENTUL BALARAJA

MUSAFAH

PKS/35/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

18

1500000001504

KLINIK UMUM & BERSALIN YULISATI

JL. RAYA SERANG KM 36 JAYANTI 10/03

DR. MAWARDI LUBIS

PKS/36/122015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

19

1500000001504

KLINIK UMUM & BERSALIN YULISATI

JL. RAYA SERANG KM 36 JAYANTI 10/03

DR. MAWARDI LUBIS

PER/ PKS/ 19 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

20

1500000001295

RS IBU DAN ANAK KELUARGA KITA

JL RAYA PLP CURUG NO.8 KM.8 CURUG

PER/TC/10/0620 15

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

21

1400000000665

RSUD BALARAJA

JL.RAYA RUMAH SAKIT NO.88 DS.TOBAT KEC. BALARAJA KAB.TANGERANG

26327666

KAB. TANGERANG

PKS/27/122015

RS.TRAUMA CENTRE

30/12/2015

31/12/2015

22

1500000000734

RUMAH SAKIT MULIA INSANI

JL.RAYA SERANG KM 16.8 SUKAMULYA CIKUPA 15710

5962790

DR.NINDYAKUSUMA KORATIWIDA,MARS

PKS / 05 / 052015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1400000000407

MA11222I

:

K14- KANTOR CABANG BEKASI CIKARANG

NAMA PROVIDER

KLINIK ANNISA II

ALAMAT JL. RAYA CIBARUSAH RUKO POIN, NO.31-R ,DESA SUKARESMI, KEC. CIKARANG SELATAN, KABUPATEN BEKASI

KODE POS

IKS TELEPON

PIMPINAN NO IKS

8976189

PT ANNISA MITRA HUSADA

PER/49/102015



AWAL IKS 01/10/2015


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1400000000406

KLINIK ANNISA IV

JL.CIBARUSAH RAYA, NO.69, DS SERANG BARU, SERANG ,KABUPATEN BEKASI

89954434


PER/50/2015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

3

1500000001951

KLINIK ANNISAIII

JL. NIAGA RAYA, RUKO GOLDEN BOULEVARD BLOK CC 5 NO 12 SENTRA INDUSTRI JABABEKA II CIKARANG

8976189


PER/42/092015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

4

1500000001324

KLINIK AS-SHOFWAN

JL. KEDUNG WARINGIN,KEC KEDUNG WARINGIN, KABUPATEN BEKASI

89140813

PT AS-SHOFWAN TUNGGAL MANDIRI

NOMOR:PER / 20 / 062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

5

1500000001323

KLINIK AS-SYIFA

JL. RAYA INDUSTRI NO.3A,KP.SEMPU GARDU, RT 04/02,DESA PASIR GOMBONG CIKARANG UTARA, KABUPATEN BEKASI

89100792

CV. AS-SYIFA ANUGERAH RAYA

PER/22/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

6

1500000001952

KLINIK BERKAT MELIMPAH JABABEKA

KAWASAN INDUSTRI JABABEKA 1B 8 CIKARANG UTARA-BEKASI

8937941

PT BERKAT MELIMPAH PRATAMA

PER/44/092015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

7

1500000000180

KLINIK CENTRAL MEDIKA 1

JL. PILAR SIKATANI NO.84 (WARUNG POJOK) SUKARAYA KARANG BAHAGI

89111103

DR. LIA NURLAELA

PER/06/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

8

1500000001529


89111103

DR. LIA NURLAELA

PER/24/062015

RS.TRAUMA CENTRE

01/06/2015

31/01/2016

9

1500000001530


89111103

DR LIA NURLAELA

PER/25/062015

RS.TRAUMA CENTRE

01/06/2015

31/01/2016

10

1400000000388

KLINIK CIKARANG MEDICAL CENTER

8934371

RS AWAL BROS HOSPITAL GROUP

PER/51/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

11

7-1199819163

KLINIK GRAHA BINA HUSADA

JL.INDUSTRI SELATAN NO.1A, BLOK NN 3A,JABABEKA 2

DR HERTI E.SILALAHI

PER/54/122015

RS.TRAUMA CENTRE

29/12/2015

30/11/2016

12

1400000000549

KLINIK GRAHA BINA HUSADA

JL.INDUSTRI SELATAN NO.1A, BLOK NN3AJABABEKA II, CIKARANG BARU

89836243

PT.GRAHA BINA HUSADA

PER/54/122015

RS.TRAUMA CENTRE

05/01/2016

30/11/2016

13

1400000000247

KLINIK INTRIMED

RUKO MEGA MALL BLOK C-2 MM 2100

89882355

PT PERSADA SARI MEDIKA

PER/33/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I

JL. PILAR ¿ SUKATANI (WARUNG POJOK) RT/RW. 005/006 DESA. SUKARAYA KECAMATAN. KARANG BAHAGIA , KABUPATEN BEKASI JL. PILAR ,SUKATANI (WARUNG POJOK) RT/RW. 005/006 DESA. SUKARAYA KECAMATAN. KARANG BAHAGIA , KABUPATEN BEKASI

17530


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

14

1500000001977

KLINIK KARUNIA MEDIKA

JL. GATOT SUBROTO NO 37 RT 03 RW 02 CKR KOTA

17211

89104266

SRI HANDAYANI

PER/53/1015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

15

1500000001977



17211

89104266

SRI HANDAYANI

PER/53/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

16

1500000001977



17211

89104266

SRI HANDAYANI

PER/53/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

17

7-1254255963

KLINIK KASIH ANUGERAH SERANG BARU

JL. RAYA CIBARUSAH, KP.BUNISARI RT.007/004, DESA SUKARAGAM, KEC. SERANG BARU , KABUPATEN BEKASI

17530

DR KETTLER SIAHAAN, MBA

PER/58/122015

RS.TRAUMA CENTRE

04/01/2016

04/11/2016

18

1400000000283


JL INDUSTRI PASIR GOMBONG JABABEKA CIKARANG

89835510


PER/34/082015

RS.TRAUMA CENTRE

01/08/2015

31/07/2016

19

1400000000220


JL RAYA CIBARUSAH NO.02 SUKARESMI

89677085

NAYAKA HUSADA 03

PER/40/082015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

20

1500000000479


JL.RAYA CIBARUSAH KP.MALAKA RT.02 RW 06

89950242


PER/14/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

21

1400000000258

KLINIK PRODIA OCCUPATIONAL HEALTH CENTRE

H.USMAR ISMAIL ,JABABEKA 2,CIKARANG

29083408

PT PRODIA OHI INTERNASIONAL

PER/35/082015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

22

1400000000389

KLINIK PUTRA MEDIKA 1

VILLA MUTIARA CIKARANG DESA CIANTRA

8971932

DR.H.MULYANA SYARIF PANIJA

PER/45/092015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

23

1500000001528


JL.RAYA CIBARUSAH, DEPAN GERBANG UTAMA VILLA MUTIARA CIKARANG

8971932

MULYANA SYARIP PANIJA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/10/2015

24

1500000001528


JL.RAYA CIBARUSAH, DEPAN GERBANG UTAMA VILLA MUTIARA CIKARANG

8971932

MULYANA SYARIP PANIJA

PER/46/102015

RS.TRAUMA CENTRE

01/11/2015

31/10/2016

25

1500000001527


JL.PERUM KOTA SERANG BARU, SERANG

89950333

H.MULYANA SYARIP PANIJA

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

30/09/2015

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

26

1500000001527


JL.PERUM KOTA SERANG BARU, SERANG

27

1500000001856

KLINIK SETIA 3

JL.RAYA SERANG CIBARUSAH, NO.41, RT 012 RW 006 SUKADAMI,CIKARANG SELATAN, KABUPATEN BEKASI

28

1500000000193

KLINIK TAMAN FIRDAUS MEDIKA

PERUMAHAN TAMAN FIRDAUS RESIDENCE BLOK A.06, NO.17

29

7-1251921754

RS AMANDA

JALAN RAYA SERANG , NO. 83 CIKARANG

30

1400000000004

RS AMANDA CIKARANG

JL RAYA SERANG, NO.83, CIKARANG

31

7-1432249443

RS ANNISA CIKARANG

JL CIKARANG BARU, NO.31, KECAMATAN CIKARANG UTARA, KAB.BEKASI

32

1500000001495

RS AS-SHOFWAN

JL. RAYA KARAWANG-BEKASI KM 30, DS BOJONGSARI,KEC KEDUNG WARINGIN, KABUPATEN BEKASI

33

1400000000055

RS BHAKTI HUSADA

JL.R.E.MARTADINATA BY PASS CIKARANGBEKASI

34

7-1254255965

RS DR SANDER.B

JL. KH.DEWANTARA NO.33 CIKARANG UTARA, KABUPATEN BEKASI

35

1500000001950

RS HARAPAN KELUARGA

JL. KASUARI RAYA KAV 1A & 1B KOTA JABABEKA CIKARANG BARU, BEKASI

36

7-1250333673

RS HOSANA LIPPO CIKARANG

JL UTAMA BIIE ,NO. 01, LIPPO CIKARANG BEKASI

37

1400000000003

RS HOSANA MEDICA CIKARANG BARU

JL ANGGREK I B2/2 JABABEKA

MA11222I

KODE POS

17330

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

89950333

H.MULYANA SYARIP PANIJA

PER/46/092015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

8971240

PT SETIA RAKSA AFINI

PER/30/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

70604934

HERI YULIANSYA, SE

PER/08/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

DR.HAMIDAH, M.KES

PER/60/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

DR HAMIDAH, M.KES

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

DR.NOOR ARIDA SOFIANA, MBA

PER/55/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

89141890

PT AS-SHOFWAN TUNGGAL MANDIRI

PER / 19 / 062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

89110896

PT HUSADA PURWAKARTA

PER/36/082015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

DR. HASAN

PER/59/122015

RS.TRAUMA CENTRE

05/01/2016

30/11/2016

PT HARAPAN INTERNASIONAL

PER/41/092015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

JOHANNES POSO

PER/56/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

JOHANES POSO

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

17530

8971643

17530

17340

89840745

17530

29620630


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

38

1200000000013

RS HOSANA MEDICA LIPPO CIKARANG

JL. RUKO THAMRIN BLOK C-3 LIPPO CIKARANG

8972472

JOHANES POSO

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

39

1500000000495

RS MEDIROSSA

JL INDUSTRI TEGAL GEDE NO.9, CIKARANG SELATAN

89833216

PT MEDIROSSA MITRA INSANI

PER/15/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

40

1500000001671

RS MEDIROSSA 2 CIBARUSAH

JL. RAYA CIBARUSAH NO.5, DESA SINDANG MULYA, KEC.CIBARUSAH, KAB.BEKASI,

89955555

H.OMIN BASUNI SH

RS MEDIROSSA 2 CIBARUSAH

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

41

1500000001378

RS MITRA MEDIKA

JL RAYA JATIWANGI-CIKEDOKAN, CIKARANG BARAT,KAB.BEKASI

98213879

PT MUTIARA ADHI MEDIKA

PER/21/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

42

1500000001857

RS RIDHOKA SALMA

JL.IMAM BONJOL NO.7, KP.GARDU SAWAH RT.001/001,DESA KALIJAYA ,KEC.CIKARANG BARAT, KABUPATEN

89116527

PT RIDHOKA SALMA

PER/31/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

43

1400000000387

RS SENTRA MEDIKA

JL RAYA INDUSTRI PASIR GOMBONG, CIKARANG, BEKASI

8904160

SENTRA MEDIKA GROUP

PER / 48 /102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

44

1500000001575

RS SETIA

JL. RAYA SERANG CIBARUSAH NO.41,KEC.CIKARANG SELATAN, KABUPATEN BEKASI

8971240

DR KURNIA PUJI ASTUTI

PER/28/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

45

1500000000844

RS SILOAM HOSPITALS LIPPOCIKARANG

JL MH THAMRIN KAV 105 LIPPOCIKARANG

29636900

SILOAM HOSPITALS

PER/18/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

46

1100000000024

RS. ANNISA CIKARANG (TC)

JL CIKARANG BARU NO 31 CIKARANG UTARA

8904165

DR. ISMAIL ALMUCHTARO MPH

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

47

1500000000471

RS. APRILIA MEDIKA

JL. RAYA SETU NO. 99 DS. LUBANG BUAYA KEC. SETU

82611565

DR. MOHAMMAD NATSIR

PER/12/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

48

1500000000472

RS. MUTIARA HUSADA

JL. RAYA SUKATANI NO.09 DS. KARANG SENTOSA KARANG BAHAGIA

89161339

DR.MOHAMMAD NATSIR

PER/13/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

49

1300000000022

RS. PERMATA KELUARGA

JL.M.H. THAMRIN KAV 129 LIPPO CIKARANG

89905588

PER/16/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

17330


SM0480



179 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

50

KODE PROVIDER

1500000001374

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

RSIA CIKARANG MEDIKA

:

ALAMAT

KODE POS

JL.KH.FUDHOLI.NO.78 CIKARANG,BEKASI

IKS TELEPON

PIMPINAN NO IKS

8902210

DR ULAM FRIDALAM

PER/23/062015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/07/2015


K15- KANTOR CABANG BANDUNG LODAYA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000873

KLINIK ALBAR

JL TERUSAN KOPO NO 371 KOPO MARGAHAYU

40225

085863333 599

YAYASAN LESTARI

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

2

1500000000873

KLINIK ALBAR

JL TERUSAN KOPO NO 371 KOPO MARGAHAYU

40225

085863333 599

YAYASAN LESTARI

PER/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1400000000252

KLINIK AVIATI KOPO

JL KOPO NO. 59 PANJUNAN - KOTA BANDUNG

40241

5232291

PT. AVIATI PRIMA CITRA

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1400000000252

KLINIK AVIATI KOPO

JL KOPO NO. 59 PANJUNAN - KOTA BANDUNG

40241

5232291

PT. AVIATI PRIMA CITRA

PER/19/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

5

1500000001810

KLINIK BHAYANGKARA HUSADA POLRES BANDUNG

JL. BHAYANGKARA NO. 1 POLRES BANDUNG - SOREANG

40911

85871980

POLRES BANDUNG

PER/17/062015

RS.TRAUMA CENTRE

22/06/2015

31/12/2015

6

1500000001810

KLINIK BHAYANGKARA HUSADA POLRES BANDUNG

JL. BHAYANGKARA NO. 1 POLRES BANDUNG - SOREANG

40911

85871980

POLRES BANDUNG

PER/16/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7

1500000001538

KLINIK INSANIYAH MEDICAL CENTRE

JL TERUSAN AL FATHU KM 17 RT 05 RW 04 DESA PAMEKARAN SOREANG

40911

85874343

PMI KAB BANDUNG

PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1500000001538

KLINIK INSANIYAH MEDICAL CENTRE

JL TERUSAN AL FATHU KM 17 RT 05 RW 04 DESA PAMEKARAN SOREANG

40911

85874343

PMI KAB BANDUNG

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

9

1500000001541

KLINIK KATAPANG

JL TERUSAN KOPO NO 65 KATAPANGSOREANG

40921

21175677

DR.FELIX KASIM, M.KES

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

10

1500000001541

KLINIK KATAPANG

JL TERUSAN KOPO NO 65 KATAPANGSOREANG

40921

21175677

DR.FELIX KASIM, M.KES

PER/18/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001537

KLINIK LUHUR MEDICA CENTRE

JL JEND SUDIRMAN NO 472/474 ANDIR BANDUNG

40182

6037679

CV LUHUR MEDICA CENTRE

PER/13/2015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001537

KLINIK LUHUR MEDICA CENTRE

JL JEND SUDIRMAN NO 472/474 ANDIR BANDUNG

40182

6037679

CV LUHUR MEDICA CENTRE

PER/19/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1400000000251


JL TERUSAN KOPO KM 12 KATAPANG KAB. BANDUNG

40921

61804614


PER/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

1400000000251



40921

61804614


PER/04/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

15

1400000000251



40921

61804614


PER/04/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

16

1500000000871

KLINIK NORMA MASITHA

JL RAYA TIMUR NO 41 BANJARAN KAB BANDUNG

40377

5944144

DR HJ ROSIDAH AGUS

PER/11/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000000871

KLINIK NORMA MASITHA

JL RAYA TIMUR NO 41 BANJARAN KAB BANDUNG

40377

5944144

DR HJ ROSIDAH AGUS

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

18

1500000000911

KLINIK RATNASARI 2

JL RAYA CIWIDEY KP PEER RT 03 RW 23 DESA CIWIDEY KEC CIWIDEY

40973

5927794

APENG HIDAYAT

PER/07/052014

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

19

1500000000911

KLINIK RATNASARI 2

JL RAYA CIWIDEY KP PEER RT 03 RW 23 DESA CIWIDEY KEC CIWIDEY

40973

5927794

APENG HIDAYAT

PER/13/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1500000000872

KLINIK SAHABAT SEHAT AMPUH

JL TERUSAN KOPO NO 593 KM 11,5 DS PANGAUBAN KATAPANG

40921

5897000

DRS AHMAD SUHANDA

PER/10/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


SM0480



181 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

21

1500000000872

KLINIK SAHABAT SEHAT AMPUH

JL TERUSAN KOPO NO 593 KM 11,5 DS PANGAUBAN KATAPANG

40921

5897000

DRS AHMAD SUHANDA

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

22

1500000000882

KLINIK SEHAT MEDIKA UTAMA

JL PANGALENGAN SITU CILEUNCA KP SIDAMUKTI RT 01 RW 04 PANGALENGAN

40378

081320605 293

APENG HIDAYAT

PER/05/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

23

1500000000882

KLINIK SEHAT MEDIKA UTAMA

JL PANGALENGAN SITU CILEUNCA KP SIDAMUKTI RT 01 RW 04 PANGALENGAN

40378

081320605 293

APENG HIDAYAT

PER/12/2016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1500000001330

KLINIK SEHAT SEJAHTERA

JL LAMAJANG NO.119 DAYEUHKOLOT

40238

5204139

DR RUKHIYAT SYAHIDIN

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

25

1500000001330

KLINIK SEHAT SEJAHTERA

JL LAMAJANG NO.119 DAYEUHKOLOT

40238

5204139

DR RUKHIYAT SYAHIDIN

PER/07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000001709

KLINIK WIDYA BHAKTI INTI

JL. MOCH TOHA NO.77 BANDUNG

40253

5201501

PT.WIDYA BHAKTI INTI

PER/15/012016

RS.TRAUMA CENTRE

01/01/2016

31/01/2016

27

1500000001709

KLINIK WIDYA BHAKTI INTI

JL. MOCH TOHA NO.77 BANDUNG

40253

5201501

PT.WIDYA BHAKTI INTI

PER/18/062015

RS.TRAUMA CENTRE

22/06/2015

31/12/2015

28

1400000000080

RSUD AL IHSAN PROV. JABAR

JL KIASTRAMANGGALA - BALEENDAH

40258

5940872

PEMDA PROVINSI JABAR

PER/03/032015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

29

1400000000080

RSUD AL IHSAN PROV. JABAR

JL KIASTRAMANGGALA - BALEENDAH

40258

5940872

PEMDA PROVINSI JABAR

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

30

1100000000025

RUMAH SAKIT IMMANUEL

JL. KOPO NO 161 KOTA BANDUNG

40241

5201051

YAYASAN BRS GK PASUNDAN

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

31

1100000000025

RUMAH SAKIT IMMANUEL

JL. KOPO NO 161 KOTA BANDUNG

40241

5201051

YAYASAN BRS GK PASUNDAN

PER/20/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

32

1400000000532

RUMAH SAKIT RAJAWALI

JL RAJAWALI NO 38 RT 03 RW 10 KEC ANDIR

40181

6011913

YAYASAN KEMANUSIAN

PER/06/012016

RS.TRAUMA CENTRE

30/12/2015

31/12/2016

MA11222I


SM0480



182 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

33

1500000001540

RUMAH SAKIT UMUM DAERAH SOREANG

JL ALUN ALUN UTARA NO 1 SOREANG

40911

5891355

PEMERINTAH DAERAH KAB. BANDUNG

PER/15/052015

RS.TRAUMA CENTRE

04/05/2015

31/12/2015

34

1500000001540

RUMAH SAKIT UMUM DAERAH SOREANG

JL ALUN ALUN UTARA NO 1 SOREANG

40911

5891355

PEMERINTAH DAERAH KAB. BANDUNG

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

35

1500000001715

SANTOSA HOSPITAL BANDUNG CENTRAL

JL KEBONJATI NO 38 BANDUNG

40181

4248555

PT SANBE PRAKARSA HUSADA

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

36

1500000001715

SANTOSA HOSPITAL BANDUNG CENTRAL

JL KEBONJATI NO 38 BANDUNG

40181

4248555


PER/012/062015

RS.TRAUMA CENTRE

15/06/2015

31/12/2015

37

1500000001388

SANTOSA HOSPITAL BANDUNG KOPO

KH. WAHID HASYIM NO 461- 463 KOPO BANDUNG

40221

54280555


PER/11/062015

RS.TRAUMA CENTRE

15/06/2015

31/12/2015

38

1500000001388

SANTOSA HOSPITAL BANDUNG KOPO

KH. WAHID HASYIM NO 461- 463 KOPO BANDUNG

40221

54280555


PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

K16- KANTOR CABANG BOGOR CILEUNGSI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001174

KLINIK ANGGI

KP CIBEBER DS KAHURIPAN KLAPANUNGGAL

29219678

YAYASAN NOGI SEHATI

PER/23/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

2

1500000001174

KLINIK ANGGI


29219678

YAYASAN NOGI SEHATI

PER/23/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

3

1500000001174

KLINIK ANGGI


29219678

YAYASAN NOGI SEHATI

PER/04/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

MA11222I


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000001514

KLINIK DERA ASSYIFA

JL RAYA NAROGONG KM 23 DESA CILEUNGSI

8234492

PT. DURASTIKA SOMA WIJAYA

PER/09/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

5

1500000001514

KLINIK DERA ASSYIFA


8234492

PT. DURASTIKA SOMA WIJAYA

PER/28/062015

RS.TRAUMA CENTRE

19/06/2015

31/12/2015

6

1500000001382

KLINIK DR IRMAN

PERUM GRIYA ALAM SENTOSA BLOK C9 NO 4 RT 10/08 PASIRANGIN CILEUNGSI

YAYASAN SUMARNO MEDIKA

PER/27/062015

RS.TRAUMA CENTRE

16/06/2015

31/12/2015

7

1500000001382

KLINIK DR IRMAN

PERUM GRIYA ALAM SENTOSA BLOK C9 NO 4 RT 10/08 PASIRANGIN CILEUNGSI

YAYASAN SUMARNO MEDIKA

PER/08/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

8

1500000001207

KLINIK DR. MARZUKI

JL RAYA CILEUNGSI JONGGOL KM 2,2

DR MARZUKI

PER/05/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

9

1500000001207

KLINIK DR. MARZUKI

JL RAYA CILEUNGSI JONGGOL KM 2,2

DR MARZUKI

PER/24/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

10

7-1552354085

KLINIK EDELWEISS

PERUMAHAN CITRA GRAND CIBUBUR RUKO CITYWALK 2 NO 1-2 JATI KARYA SAMPURNA BEKASI

16820

DR AFRIYANTI SANDHI

PER/12/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

11

1500000001990

KLINIK EDELWEISS

RUKO CITYWALK 2 NO 1-2 CITRA GRAN CIBUBUR

17435

84303724

DR AFRIYANTI SANDHI

PER/36/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

12

1500000001690

KLINIK EKA MEDIKA

JL RAYA NAROGONG NO 116 KLAPANUNGGAL

16820

29289475

DR HARUMITI RAMIL,MKK

PER/11/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

13

1500000001690

KLINIK EKA MEDIKA

JL RAYA NAROGONG NO 116 KLAPANUNGGAL

16820

29289475

DR HARUMITI RAMIL,MKK

PER/30/062015

RS.TRAUMA CENTRE

26/06/2015

31/12/2015

14

1500000001687

KLINIK GRACIA


16820

SURYATI SARI ARUM, SKOM

PER/29/062015

RS.TRAUMA CENTRE

26/06/2015

31/12/2015

15

1500000001687

KLINIK GRACIA


16820

SURYATI SARI ARUM, SKOM

PER/10/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1500000001331

KLINIK MH THAMRIN MEKARSARI

RUKO EBONY BLOK 23 RT 006/004 DESA CILEUNGSI

8235052

DR RISKA ARISKA YULIANTI

PER/06/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

17

1500000001331

KLINIK MH THAMRIN MEKARSARI

RUKO EBONY BLOK 23 RT 006/004 DESA CILEUNGSI

8235052

DR RISKA ARISKA YULIANTI

PER/25/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

18

1500000001383

KLINIK PKO MUHAMMADIYAH

PERUM PTSC JL ANGGREK BLOK A NO 12 KEC CILEUNGSI

DR NUR CAHYANINGSIH

PER/07/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

19

1500000001383

KLINIK PKO MUHAMMADIYAH

PERUM PTSC JL ANGGREK BLOK A NO 12 KEC CILEUNGSI

DR NUR CAHYANINGSIH

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

20

1500000001691

RS HERMINA MEKARSARI

JL RAYA CILEUNGSI JONGGOL KM 1

16820

29232525

VIVI FRIYATNI, SKM

PER/01/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

21

1500000001691

RS HERMINA MEKARSARI

JL RAYA CILEUNGSI JONGGOL KM 1

16820

29232525

VIVI FRIYATNI, SKM

PER/31/062015

RS.TRAUMA CENTRE

26/06/2015

31/12/2015

22

1500000001927

RS PERMATA JONGGOL

JL RAYA JONGGOL NO 1 A SUKAMANAH JONGGOL

16120

89931333

DR EVY FEBRINA NURPENI, MARS

PER/03/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

23

1500000001927

RS PERMATA JONGGOL

JL RAYA JONGGOL NO 1 A SUKAMANAH JONGGOL

16120

89931333

DR EVY FEBRINA NURPENI, MARS

PER/32/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

24

1400000000327

RSTC MH THAMRIN CILEUNGSI

JL RAYA NAROGONG KM 16 LIMUSNUNGGAL CILEUNGSI

8235052

DR ABDUL RADJAK

PER/35/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

25

1400000000327

RSTC MH THAMRIN CILEUNGSI

JL RAYA NAROGONG KM 16 LIMUSNUNGGAL CILEUNGSI

8235052

DR ABDUL RADJAK

PER/02/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

26

1500000000590

TC RSIA KENARI GRAHA MEDIKA

GRIYA KENARI MAS BLOK B2 CILEUNGSI BOGOR

8230426

DRA FATIMAH

PER/21/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

KANTOR CABANG

MA11222I

:

K17- KANTOR CABANG TANGERANG CIMONE


SM0480



185 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

1

1500000001870

KLINIK RATNA MEDIKA

JL.METROLITE RAYA BLOK SQ 2 NO.3 PURI JATAKE INDAH

2

1400000000281

KLINIK SAHABAT

JL TELESONIK UJUNG NO 65 KEL BUNDERT RT 09/02 CIKUPA TANGERANG

3

1500000000649

RS DINDA

GALUH NO 2 JATIUWUNG

15133

4

1500000000649

RS DINDA


5

1500000000649

RS DINDA

6

1500000001827

7

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/27/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/5015

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

PT DINDA MEDISTRA

PER/04/042016

RS.TRAUMA CENTRE

26/01/2016

31/12/2016

15133

PT DINDA MEDISTRA

PER/04/012016

RS.TRAUMA CENTRE

26/01/2016

31/12/2016


15133

PT DINDA MEDISTRA

PER/14/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

RS MELATI

JL MERDEKA NO 92 KEL GERENDENG KARAWACI KOTA TANGERANG

15111

5523945

PT MELATI MEDIKA SEJAHTERA

PER/28/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

1100000000004

RSU AN NISA

JL GATOT SUBROTO NO 96 KM 3, CIBODAS

5525564

DR EDIANSYAH, MARS

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

8

1100000000004

RSU AN NISA

JL GATOT SUBROTO NO 96 KM 3, CIBODAS

5525564

DR EDIANSYAH, MARS

PER/05/2016

RS.TRAUMA CENTRE

27/01/2016

31/12/2016

9

1100000000005

RSU ARIYA MEDIKA

JL INDUSTRI RAYA I BLOK A NO.1-10 JATAKE

5902226

DR E TRISNO SUSILO

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KANTOR CABANG

MA11222I

:

59300041

K18- KANTOR CABANG DEPOK


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

04047

ASY-SYIFA MEDICAL CENTER

JL RAYA DEPOK CINERE NO 9 PARUNG BINGUNG SAWANGAN DEPOK

2

1500000001929

KLINIK BHAKTI JAYA

JL. KARTINI - CITAYAM RAYA NO.18 A

3

1500000001929

KLINIK BHAKTI JAYA

4

1500000001808

5

KODE POS

IKS TELEPON

PIMPINAN NO IKS

77883905

DR SOBARI

9878341

16411

77203062

DRG.SRI SULISWATI,MM

PER/15/072015

JL. KARTINI - CITAYAM RAYA NO.18 A

16411

77203062

DRG.SRI SULISWATI,MM

KLINIK IRENK MEDIKA

JL BAHAGIA RAYA NO 18 DEPOK TIMUR

16413

7715039

1500000001808

KLINIK IRENK MEDIKA

JL BAHAGIA RAYA NO 18 DEPOK TIMUR

16413

6

1500000001922

KLINIK YANI MEDIKA

JL KARTINI NO 48 RT.03/09 KEL DEPOK KEC PANCORAN MAS

7

1500000001922

KLINIK YANI MEDIKA

8

1500000001971

9

TIPE IKS

AWAL IKS

AKHIR IKS

22/09/2015

30/11/2015

FFS

01/08/2015

31/12/2015

PER/32/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

ARUJI AMBAR SUKOCO, SE

PER/31/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7715039

ARUJI AMBAR SUKOCO, SE

PER/11/062015

FFS

01/07/2015

31/12/2015

16414

77219553

DR YANI HARYANI

PER/14/062015

FFS

01/07/2015

31/12/2015

JL KARTINI NO 48 RT.03/09 KEL DEPOK KEC PANCORAN MAS

16414

77219553

DR YANI HARYANI

PER/33/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PRAKTEK DR MAS'UD

JL CINERE RAYA PERUMAHAN GRIYA CINERE 2 KAV 48 NO 12A LIMO

16421

7533780

DR. MAS'UD

PER/21/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

1500000001971

PRAKTEK DR MAS'UD

JL CINERE RAYA PERUMAHAN GRIYA CINERE 2 KAV 48 NO 12A LIMO

16421

7533780

DR. MAS'UD

PER/34/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

10

1400000000184

RS BHAKTI YUDHA

JL RAYA SAWANGAN NO 2A DEPOK

16511

7520082

THAMAS INVESTAMA GUNA

PER/27/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

11

1400000000184

RS BHAKTI YUDHA

JL RAYA SAWANGAN NO 2A DEPOK

16511

7520082

THAMAS INVESTAMA GUNA

PER/13/062015

RS.TRAUMA CENTRE

05/06/2015

31/12/2015

12

1400000000183

RS BHAYANGKARA SIKESJAS KORBRIMOB

JL RAYA AKSES UI KELAPA DUA DEPOK

87704691

DR TAUFIK

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1400000000183

RS BHAYANGKARA SIKESJAS KORBRIMOB

JL RAYA AKSES UI KELAPA DUA DEPOK

87704691

DR TAUFIK

PER/18/062015

RS.TRAUMA CENTRE

06/06/2015

31/12/2015

14

1400000000528

RS CITRA MEDIKA DEPOK

JL.RAYA KALIMULYA NO.68 CILODONG KOTA KEMBANG DEPOK

29671000

DR NENCY

PER/28/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

15

1500000001916

RS PERMATA DEPOK

JL RAYA MUCHTAR NO.22 SAWANGAN DEPOK

16511

29669000

PT MUFIDAH MEDIKA SAWANGAN

PER/10/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

16

1500000001916

RS PERMATA DEPOK

JL RAYA MUCHTAR NO.22 SAWANGAN DEPOK

16511

29669000


PER/29/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

17

1500000001811

RS PERMATA DEPOK

JL RAYA MUCHTAR NO 22 SAWANGAN

16511

29669000


PER/10/062015

FFS

01/07/2015

31/12/2015

18

1400000000181

RS SENTRA MEDIKA CISALAK

JL RAYA JAKARTA BOGOR KM 33 CISALAK DEPOK

8743790

DR HERMAN WIDYATOMO

PER/22/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

19

1400000000181

RS SENTRA MEDIKA CISALAK

JL RAYA JAKARTA BOGOR KM 33 CISALAK DEPOK

8743790

DR HERMAN WIDYATOMO

PER/12/062015

RS.TRAUMA CENTRE

06/06/2015

31/12/2015

20

1400000000182

RS SIMPANGAN DEPOK

JL RAYA JAKARTA BOGOR KM 36 SUKAMAJU DEPOK

D WARSITO

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1400000000182

RS SIMPANGAN DEPOK

JL RAYA JAKARTA BOGOR KM 36 SUKAMAJU DEPOK

D WARSITO

PER/17/062015

RS.TRAUMA CENTRE

10/06/2015

31/12/2015

22

1400000000180

RS TUGU IBU

JL RAYA JAKARTA BOGOR KM 29 CIMANGGIS DEPOK

8710870

H MARIS RINALDI

PER/23/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1400000000180

RS TUGU IBU

JL RAYA JAKARTA BOGOR KM 29 CIMANGGIS DEPOK

8710870

H MARIS RINALDI

PER/16/062015

RS.TRAUMA CENTRE

10/06/2015

31/12/2015

24

1400000000285

RSTC GRHA PERMATA IBU

JL KH USMAN NO 168 BEJI KUKUSAN DEPOK

7778899

DR PARAMITA

PER/25/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

25

KODE PROVIDER

1400000000285

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

RSTC GRHA PERMATA IBU

:

ALAMAT

KODE POS

JL KH USMAN NO 168 BEJI KUKUSAN DEPOK

IKS TELEPON

NO IKS 7778899

DR PARAMITA

PER/19/072015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/08/2015


K19- KANTOR CABANG TANGERANG BSD

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

1

1500000001019

BLKI PROVINSI BANTEN

JL. RAYA SERPONG KM 12 SERPONG UTARA KOTA TANGSEL

2

1500000000448

KLINIK AMIRA

GRIYA LOKA BSD TANGSEL

3

1500000001463

KLINIK ASA MEDIKA

4

1500000000621

KLINIK DIANA PERMATA MEDIKA

JL MH. THAMRIN KAV. 888C PANUNGGANGAN PINANG

5397314

5

1500000000323

KLINIK DR RANNY

JL BUARAN RAYA RT 003/001 SERPONG

75874222

6

1500000000441

KLINIK MAKMUR JAYA

JL CEGER RAYA - PONDOK AREN

7

1500000000440

KLINIK MAKMUR JAYA I CIPUTAT

8

1500000000442

KLINIK MAKMUR JAYA II PAMULANG

MA11222I

PIMPINAN

TIPE IKS

AWAL IKS

AKHIR IKS

PROVINSI BANTEN

PER/19/052015

RS.TRAUMA CENTRE

26/05/2015

31/05/2016

DR MURTININGRUM

PER/13/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

CV HOMY MEDICARE / ALEX

PER/26/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

DR. HJ. DIANA FACHRUDIN

PER/015/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PER/07/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

DR AYAT RAHAYU SP.RAD. MKES

PER/11/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

CIPUTAT TIMUR

DR AYAT RAHAYU SP.RAD. M.KES

PER/12/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

CIPUTAT TIMUR

DR AYAT RAHAYU SP.RAD MKES

PER/10/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

5383042


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7562156

DR. HJ. NITA GILIK, MM

PER/27/062015

RS.TRAUMA CENTRE

22/06/2015

30/06/2016

15310

5386400

JAMES TAMPUBOLON

PER/31/072015

RS.TRAUMA CENTRE

10/07/2015

09/07/2016

15310

5386400

JAMES TAMPUBOLON

PER/31/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

70947446

INDRA GUSMARDI MARAN

PER/28/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

DR HJ SITI MURWANI

PER/08/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

DR. BAMBANG SUTOTO

PER/23/062015

RS.TRAUMA CENTRE

15/06/2015

30/06/2016

PT. BETHSAIDA HOSPITAL INTERNATIONAL

PER/14/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

7490018

PT. BHINEKABAKTIHUSADA

PER/017/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

JL RAYA JOMBANG NO 56 BINTARO SEKTOR IX CIPUTAT TANGSEL

7456379

YAYASAN ICHSAN

PER/21/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

RS MEDIKA BSD

JL LETNAN SOETOPO KAV KOM III A NO 7 BSD CITY SERPONG

5373396

PT KHASANAH PUTERA JAKARTA MEDIKA

PER/18/052015

RS.TRAUMA CENTRE

01/06/2015

30/05/2016

7-1679975283

RS OMNI ALAM SUTERA

JL ALAM SUTERA BOULEVARD KAV 25 SERPONG

53125555

PT SARANA MEDITAMA INTERNATIONAL

PER/01/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

1400000000079

RS PERMATA PAMULANG

JL RAYA SILIWANGI NO 1A PAMULANG

74704999

DR TAUFIK ZAIN SPOG (K)

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

9

1500000001521

KLINIK PUTI HANDIYAH

10

1500000001875

KLINIK RAJA MEDIKA

JL CENDANA 2 RT /RW 005/004 NO 17 KAV SERPONG

11

1500000001875

KLINIK RAJA MEDIKA

JL CENDANA 2 RT /RW 005/004 NO 17 KAV SERPONG

12

1500000001613

KLINIK RAZZAAQ

JL BHAYANGKARA RAYA NO 9 RT/RW 001/004 PONDOK JAGUNG TIMUR SERPONG

13

1500000000443

KLINIK SURADITA

JL WIJAYA KUSUMA RAYA 10 - 11 PERUMNAS SURADITA

14

1500000001286

KLINIK TIGA MANDIRI

15

1500000000512

RS BETHSAIDA HOSPITAL

GADING SERPONG

16

1500000000709

RS BHINEKA BAKTI HUSADA

JL. CABE RAYA NO. 17 PAMULANG

17

1500000001210

RS IMC BINTARO

18

1500000001018

19

20

MA11222I

74711292

15325


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Periode : 01012015 s/d 31122016

NO

21

KODE PROVIDER

1500000001209

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

RS SARI ASIH CIPUTAT

:

ALAMAT

KODE POS

JL OTISTA RT 001/011 KELURAHAN CIPUTAT KEC CIPUTAT KOTA TANGSEL

IKS TELEPON

PIMPINAN NO IKS

7410808

PT SARI ASIH MANGUN PERSADA

PER/20/052015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/06/2015


L00- KANTOR CABANG SEMARANG PEMUDA

NAMA PROVIDER

ALAMAT

1

1500000001801

BALAI PELATIHAN TRANSMIGRASI DAN PENYANDANG CACAT PROV JATENG

2

1500000001753


JL JEND SUDIRMAN NO187-189 RUKO SILIWANGI PLAZA D2 SMG

3

1500000001800

KLINIK PERMATA SEHAT

4

1500000001720

5

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6720566

M NATSIR NOOR EFFENDY SH MSI

PER/17/062015

RS.TRAUMA CENTRE

30/06/2015

29/06/2016

50263

91086136


PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JL BUKIT BARISAN C1 NO 11

50184

7628785

DR YETTI NASTUTI

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PUSKEMAS BULU LOR

JL BANOWATI SELATAN II SEMARANG

50179

3548550

ENDAH EMAYANTI SKM MSI

PER/14/4/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1500000001719

PUSKESMAS BANDARHARJO

JL CUMI-CUMI RAYA BANDARHARJO SEMARANG

50175

3564787

TRI SUSILO HADI SKM MKES

PER/14/3/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6

1500000001734

PUSKESMAS BANGETAYU

JL RAYA BANGETAYU GENUK SMG

50115

6584353

DR SURYANTO SETYO PRIHADI

PER/14/16/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000001765

PUSKESMAS BOJA 01

JL RAYA BEBENGAN NO 201C BOJA

51381

571025

DR LELY YULIANTY

PER/15/20/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1500000001774

PUSKESMAS BOJA 2

JL DESA NGABEAN

51381

41001962

DR AGUS PRIBADI

PER/15/21/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

JL BRIGJEN SUDIARTO NO 375 SEMARANG


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

9

1500000001796

PUSKESMAS BRANGSONG 1

JL SIDOREJO NO 43 SIDOREJO BRANGSONG

51371

3688944

DR WIWIEN YUNITA INDRIYATI

PER/15/9/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000001767

PUSKESMAS BRANGSONG 2

JL LETNAN SUYONO NO 10 BRANGSONG

51371

383107

DR SRIYATI

PER/15/10/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

7-1435412603

PUSKESMAS BRATI

JL. RAYA KUDUS KRONGGEN PURWODADI NO. 20, KEC. BRATI

58153

085290455 655

MURSIYATI, SKM

PER/22-1/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

12

1500000001722

PUSKESMAS BUGANGAN

JL CILOSARI RAYA SEMARANG

50126

3546061

DRG RAHMA DEVI

PER/14/5/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

13

1500000001797

PUSKESMAS CANDI LAMA

JL DR WAHIDIN NO 22 SEMARANG

8310515

DRG ERMI NURYANTI MARS

PER/14/13/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

7-1435686266

PUSKESMAS GABUS I

JL. TAMAN SARI DS. SULUSARI, KEC. GABUS

58183

SOEPARNO, SKM

PER/22-2/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

15

7-1435751247

PUSKESMAS GABUS II

JL SADANG DS. KARANGREJO, KEC. GABUS

58183

TOTOK EKO SUBANDRIYO, SKM

PER/22-3/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

16

1500000001730

PUSKESMAS GAYAMSARI

JL SLAMET RIYADI NO 4A SMG

6744855

DR ASRI NUGRAHINI K

PER/14/12/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

17

1500000001781

PUSKESMAS GEMUH 1

JL PUSKESMAS NO 15 PAMRIHAN

388105

DR HJ SITI QOMARIYAH

PER/15/13/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

18

1500000001782

PUSKESMAS GEMUH 2

DS GEBANG KEC GEMUH

5704550

DR ANDI SETIAWAN

PER/15/14/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

19

1500000001733

PUSKESMAS GENUK

JL GENUKSARI RAYA GENUK SMG

50117

8584188

DR RENI ERVINA

PER/14/30/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

20

7-1435773598

PUSKESMAS GEYER I

JL. RAYA SOLO PURWADADI, KEC. GEYER

58172

00551107

DR. AGUNG PROBO M, M.SI

PER/22-4/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

MA11222I

51351


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

EDI SUCIPTO, S.KEP.M.KES

PER/22-5/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

DR. WIWIK WIBAWA

PER/22-6/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

DRG. SISWANTO HANANTA

PER/22-7/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

029277030 06

DR. AGUS BUDIYANTO

PER/22-8/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

58164

029253332 6

DR. ARIEF GUNAWAN

PER/22-9/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

58164

029251353 488

DR. SUWINDI

PER/2210/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

JL RAYA GUNUNGPATI-UNGARAN SMG

6932140

DR YUNI ASTUTI

PER/14/22/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PUSKESMAS HALMAHERA

JL HALMAHERA RAYA NO 38 SEMARANG

8414894

DR MUH HIDAYANTO

PER/14/27/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1500000001731

PUSKESMAS KAGOK

JL TELOMOYO NO 3 SMG

8312573

IDA ULI BASA BUTAR BUTAR SKM

PER/14/14/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

30

1500000001762

PUSKESMAS KALIWUNGU

JL RAYA KALIWUNGU NO 9A

382012

DR FATCHROYATI SUSANA

PER/15/22/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

31

1500000001771

PUSKESMAS KALIWUNGU SELATAN

JL RAYA BOJA KALIWUNGU DS DARUPONO

92080045

DR HESTI SULISTIYANINGSIH

PER/15/23/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

32

1500000001793

PUSKESMAS KANGKUNG 1

JL KH IBRAHIM NO 6 KANGKUNG

383181

DR ISTIAWATI

PER/15/25/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

21

7-1435791349

PUSKESMAS GEYER II

DS. BANGSRI, KEC. GEYER

58172

22

7-1444349893

PUSKESMAS GODONG I

JL. RAYA SEMARANG, KEC. GODONG

58162

23

7-1444478904

PUSKESMAS GODONG II

DS. SAMBUNG, KEC. GODONG

58162

24

7-1444574355

PUSKESMAS GROBOGAN

JL. PUGER NO.160, KEC. GROBOGAN

58152

25

7-1444762696

PUSKESMAS GUBUG I

JL. A. YANI 119, KEC. GUBUG

26

7-1444853077

PUSKESMAS GUBUG II

JL. RAYA PILANG JEKETRO KM. 7, KEC.GUBUG

27

1500000001743

PUSKESMAS GUNUNGPATI

28

1500000001721

29

MA11222I

50111

51353

029265932 2


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193 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

33

1500000001794

PUSKESMAS KANGKUNG 2

DS SENDANG KULON KEC KANGKUNG

51353

5703134

DR UMIYATI

PER/15/26/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

34

1500000001725

PUSKESMAS KARANG AYU

JL KENCONO WUNGU III NO 28 SMG

50144

7606065

DR SITI MASFUFAH MKES

PER/14/7/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

35

1500000001723

PUSKESMAS KARANG DORO

JL RADEN PATAH SEMARANG

50122

3540035

DR WAHYUDI

PER/14/28/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

36

1500000001746

PUSKESMAS KARANG MALANG

JL RM SOEBAGIONO TJONDROKUSUMO MIJEN SMG

70783410

DR ANASIH RACHMAWATI

PER/14/35/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

37

1500000001751

PUSKESMAS KARANGANYAR

JL TIRTO KARANGANYAR TUGU SMG

50135

8662080

DR SRI MAHARSI

PER/14/26/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

38

7-1444951638

PUSKESMAS KARANGRAYUNG I

JL. GONDONG JUWANGI, KEC. KARANGRAYUNG

58163

AGUNG DWI SUJATMOKO, SKM

PER/2211/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

39

7-1445380831

PUSKESMAS KARANGRAYUNG II

JL. RAYA TELAWAH, KEC. KARANGRAYUNG

58163

PUJIYONO, SKM,M.KES

PER/2212/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

40

7-1445437092

PUSKESMAS KEDUNGJATI

JL. RAYA KEDUNGJATI, KEC. KEDUNGJATI

58167

029265808 8

DR. HARDJOKO

PER/2213/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

41

1500000001737

PUSKESMAS KEDUNGMUNDU

SAMBIROTO RT 1/RW 1 TEMBALANG SMG

50273

6717053

TURI SETYOWATI

PER/14/18/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

42

1500000001758

PUSKESMAS KENDAL 01

JL PAHLAWAN I SUKODONO KENDAL

51311

3843409

DINAS KESEHATAN KAB KENDAL

PER/15/29/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

43

1500000001769

PUSKESMAS KENDAL 2

JL KARANG KEMBANG KARANGSARI

51318

383309

DR SITI MUSRIAH

PER/15/30/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

44

7-1445504163

PUSKESMAS KLAMBU

DS. KLAMBU, KEC. KLAMBU

58154

081575586 160

SIGIT TYASMONO, SKM

PER/2214/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

45

7-1445537804

PUSKESMAS KRADENAN I

JL. SURYOJENGGOLO 16 KUWU, KEC. KRADENAN

58182

029276124 1

DR. YATINO

PER/2215/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

46

7-1445609485

PUSKESMAS KRADENAN II

JL. HONGGO KUSUMAN 13, KEC KRADENAN

58182

029276157 7

SUBANDI, SKM

PER/2216/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

47

1500000001728

PUSKESMAS KROBOKAN

JL ARIBUANA NO 1 SEMARANG

50141

7610084

SATIDA F SKM MKES

PER/14/10/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

48

1500000001724

PUSKESMAS LAMPER TENGAH

JL LAMPER TENGAH GANG XV SEMARANG

84444808

DR SULISTYOWATI

PER/14/6/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

49

1500000001726

PUSKESMAS LEBDOSARI

JL TAMAN LEBDOSARI RT 7/RW VI SMG

50145

7610207

DR UMI QULSUM MKES

PER/14/8/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

50

1500000001768

PUSKESMAS LIMBANGAN

JL RAYA LIMBANGAN NO 3

51383

3673283

DR SLAMET RIYANTO

PER/15/8/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

51

1500000001750

PUSKESMAS MANGKANG

JL JEND OERIP SOEMOHARJO KM 16 SMG

50156

8660675

DR BUDI MULYANTO

PER/14/37/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

52

1500000001727

PUSKESMAS MANYARAN

JL ABDUR RAHMAN SALEH 267 SMG

50149

7601883

SUFARKAH SKM

PER/14/9/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

53

1500000001745

PUSKESMAS MIJEN

JL RAYA MIJEN NO 146-148 SMG

7711083

DR YETTI NASTUTI

PER/14/34/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

54

1500000001718

PUSKESMAS MIROTO

JL TAMAN SETERAN RAYA NO 3 SEMARANG

3552542

SUMARTOPO SKM

PER/14/2/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

55

1500000001749

PUSKESMAS NGALIYAN

JL WISMA SARI RAYA NGALIYAN SMG

7608795

DR WAHIDAH NOFRIDALIA

PER/14/36/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

56

1500000001792

PUSKESMAS NGAMPEL

JL SUNAN AMPEL KM 2 NGAMPEL KULON

383084

SUGENG UJI HARTONO SKM

PER/15/12/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

50134


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195 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

57

7-1445738346

PUSKESMAS NGARINGAN

JL. RAYA BLORA, KEC. NGARINGAN

58193

081225177 040

M. ABDUL RAUF, S.KEP, M.KES

PER/2217/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

58

1500000001729

PUSKESMAS NGEMPLAK SIMONGAN

JL SRININDITO IV RT 8/RW 1 SMG

50148

7610212

SRI ANDRIYANI SKM MKES

PER/14/11/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

59

1500000001739

PUSKESMAS NGESREP

JL TEUKU UMAR NO 271 SMG

50262

7474113

DR AHNAF

PER/14/32/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

60

1500000001740

PUSKESMAS PADANGSARI

JL MERANTI RAYA BANYUMANIK SMG

50261

7472460

DR JULIUS TJANDRA

PER/14/20/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

61

1500000001777

PUSKESMAS PAGERUYUNG

DS PUCAKWANGI PAGERUYUNG

51361

5790987

DR SULASIH

PER/15/4/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

62

1500000001752

PUSKESMAS PANDANARAN

JL PANDANARAN NO 79 SEMARANG

50144

8311470

DR ANTONIA S

PER/14/29/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

63

1500000001760

PUSKESMAS PATEAN

JL SUKOREJO PARAKAN KM 4 PAGERSARI PATEAN

51364

451531

MOH JAMALUDHIN SKM MM

PER/15/5/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

64

1500000001764

PUSKESMAS PATEBON 02

DS KEBONHARJO KEC PATEBON KENDAL

51351

3686051

DR ISTIQOMAH TRI HANDAYANI

PER/15/28/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

65

1500000001795

PUSKESMAS PATEBON 1

DS PIDODOKULON KEC PATEBON

51351

5790390

DR ULIA HUDA

PER/15/27/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

66

1500000001732

PUSKESMAS PEGANDAN

JL KENDENG BARAT III / 2 SMG

50274

8445809

SRI ANIHANDAYANI SKM MKES

PER/14/15/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

67

1500000001761

PUSKESMAS PEGANDON

JL RAYA TEGOREJO PEGANDON

383705

DR NUR WIDYASTUTI

PER/15/11/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

68

7-1445782077

PUSKESMAS PENAWANGAN I

JL. RAYA PURWODADI, KEC. PENAWANGAN

029242710 70

DR. DIANA FAJAR UDHARITA

PER/2218/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

MA11222I

58161


SM0480



196 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

69

7-1445869188

PUSKESMAS PENAWANGAN II

JL. RAYA SEDADI KM 3, KEC. PENAWANGAN

58161

70

1500000001776

PUSKESMAS PLANTUNGAN

JL RAYA NO 21 PLANTUNGAN DS TIRTOMULYO

51362

71

1500000001763

PUSKESMAS PLT CEPIRING

JL STASIUN SEMUT NO 9 CEPIRING

72

1500000001717

PUSKESMAS PONCOL

73

1500000001742

74

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. AGUS BUDI SARJONO, MM

PER/2219/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

451714

DR BUDI MULYONO

PER/15/1/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

51352

383475

DR SRI INAYATI

PER/15/24/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JL IMAM BONJOL NO 114

50132

3546053

DRG SUTANTI

PER/14/1/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

PUSKESMAS PUDAK PAYUNG

JL PERINTIS KEMERDEKAAN SMG

50269

7462711

SUMARSONO SKM MKES

PER/14/21/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7-1445943179

PUSKESMAS PULOKULON I

JL. RAYA . PANUNGGALAN NO 137, KEC. PULOKULON

58181

081325129 862

RIJADI AZIKIN, SKM, M.KES

PER/2220/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

75

7-1445969030

PUSKESMAS PULOKULON II

JL. DAYANG KUWU NO.18, KEC. PULOKULON

58181

DR. PUNGKI ADHITAMA P

PER/2221/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

76

7-1446062441

PUSKESMAS PURWODADI I

JL. GAJAH MADA NO. 1, KEC. PURWODADI

58111

029242154 1

DR. RINI ARYANTI

PER/2222/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

77

7-1446286013

PUSKESMAS PURWODADI II

DS. NAMBUHAN, KEC PURWODADI

58111

029277014 14

DR. RINJANI SURYANINGSIH, MA

PER/2223/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

78

1500000001748

PUSKESMAS PURWOYOSO

JL SILIWANGI NO 572 SMG

50263

7612927

DRS BUDI MULYONO MKES

PER/14/25/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

79

1500000001780

PUSKESMAS RINGINARUM

DS RINGINARUM KEC RINGINARUM

5701268

DR ENDAH PUSPITORINI

PER/15/15/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

80

1500000001738

PUSKESMAS ROWOSARI

JL RAYA ROWOSARI NO 1 SMG

7019382

HERI WIBOWO SKM

PER/14/19/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


SM0480



197 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

81

1500000001757

PUSKESMAS ROWOSARI 02 KENDAL

JL RAYA SOEKARNO HATTA WONOTENGGANG KENDAL

51311

641541

DINAS KESEHATAN KAB KENDAL

PER/15/19/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

82

1500000001779

PUSKESMAS ROWOSARI 1

DS SENDANG DAWUHAN KEC ROWOSARI

51354

5792354

DR YUNI WIDIASTUTI

PER/15/18/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

83

1500000001744

PUSKESMAS SEKARAN

JL RAMBUTAN NO 44 SEKARAN GUNUNGPATI SMG

70772838

DR LILIK FARIDAH

PER/14/23/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

84

1500000001773

PUSKESMAS SINGOROJO 1

JL NGAREANAK SINGOROJO

572328

SUTRISNO SKEP NERS

PER/15/6/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

85

1500000001772

PUSKESMAS SINGOROJO 2

JL RAYA BOJA KALIWUNGU KM 20 KERTOSARI SINGOROJO

571928

DR DWI YULIAWATI

PER/15/7/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

86

1500000001741

PUSKESMAS SRONDOL

JL SETIABUDI NO 209 SMG

50263

7472852

DR NOEGROHO EDY RIJANTO MKES

PER/14/33/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

87

1500000001759

PUSKESMAS SUKOREJO 01

JL BANARAN NO 4 SUKOREJO

51363

451314

DR MUKHAMMAD TOHA

PER/15/2/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

88

1500000001775

PUSKESMAS SUKOREJO 2

JL SUKOREJO NGADIWARNO

51363

452104

DR I MADE ASTAWA

PER/15/3/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

89

1500000001747

PUSKESMAS TAMBAK AJI

JL RAYA WALISONGO KM 9 SMG

8661743

DRG SAKINAH

PER/14/24/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

90

7-1446397684

PUSKESMAS TANGGUNGHARJO

DS. TANGGUNGHARJO NO. 12A, KEC. TANGGUNGHARJO

58166

DR. KUSAINI

PER/2224/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

91

7-1446533475

PUSKESMAS TAWANGHARJO

JL. RAYA PURWODADI BLORA POJOK, KEC. TAWANGHARJO

58191

DRG. RENDRA M

PER/2225/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

92

7-1446647286

PUSKESMAS TEGOWANU

JL. GATOT SUBROTO NO. 128, KEC. TEGOWANU

58165

DR. EKO TAKARIYANTO

PER/2226/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

MA11222I

029251351 50


SM0480



198 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

93

1500000001736

PUSKESMAS TLOGOSARI KULON

JL TAMAN SATRIO MANAH NO 2 TLOGOSARI SMG

50196

6717051

DR INDAH WIDIASTUTI

PER/14/31/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

94

1500000001735

PUSKESMAS TLOGOSARI WETAN

JL SOEKARNO HATTA SMG

50111

8713083

DR NURHAYATI MKES

PER/14/17/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

95

7-1446759157

PUSKESMAS TOROH I

JL. RAYA SOLO 171 DS. DEPOK, KEC. TOROH

58171

029255219 2

AGUS SETIJORINI, SKM

PER/2227/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

96

7-1446805408

PUSKESMAS TOROH II

DS. TUNGGAK, KEC.TOROH

58171

DR. ENDAH YULI RATNAWATI

PER/2228/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

97

1500000001766

PUSKESMAS WELERI 02

DS KARANGANOM KEC WELERI

51355

643245

TEGUH PRASOJO AMD KEP

PER/15/17/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

98

1500000001778

PUSKESMAS WELERI 1

JL TAMTAMA NO 3 WELERI

51355

641023

DR SRI JOKO PITOYO

PER/15/16/06201 5

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

99

7-1446854619

PUSKESMAS WIROSARI I

JL. KUSUMA BANGSA, KEC. WIROSARI

58192

029276102 9

DJAKA WIDADA B, SKM

445/1722/2014

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

100

7-1446890010

PUSKESMAS WIROSARI II

JL TAMBAK NO. 1 DS. KARANG ASEM, KEC. WIROSARI

58192

SUTRISNO, SKM

PER/2230/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

101

1400000000218

RS BHAKTI WIRA TAMTAMA

JL DR SOETOMO NO 17

3555944

PER/017/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

102

1400000000218

RS BHAKTI WIRA TAMTAMA

JL DR SOETOMO NO 17

3555944

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

103

7-953735513

RS COLUMBIA ASIA SEMARANG

JL SILIWANGI NO 143 SEMARANG

PT BELEFINA SARANA MEDIKA

PER/28/122015

RS.TRAUMA CENTRE

11/12/2015

30/11/2016

104

1500000000212

RS ISLAM KENDAL

JL AR RAHMAH NO 17 WELERI KENDAL

DRG EDI SUMARWANTO MM MH KES

PER/25/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

50131

641870


SM0480



199 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

105

1500000000212

RS ISLAM KENDAL

JL AR RAHMAH NO 17 WELERI KENDAL

641870

DRG EDI SUMARWANTO MM MH KES

PER/022/022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

106

1500000001046

RS MUHAMMADIYAH GUBUG

JL LETJEN R SOEPRAPTO NO 12 GUBUG

533102

DR M ARIF RIDA

PER/09/052015

RS.TRAUMA CENTRE

11/05/2015

10/05/2016

107

1500000000223

RS PANTI RAHAYU YAKKUM PURWODADI

JL LET JEND. R SUPRAPTO 06 PURWODADI

421087

DR SUNARIMA, M.KES

PER/024/022015

RS.TRAUMA CENTRE

01/01/2015

31/12/2016

108

1500000001404

RS PANTIWILASA DR CIPTO SEMARANG

JL DR CIPTO NO 50 SEMARANG

3546040

YAKKUM

PER/11/062015

RS.TRAUMA CENTRE

04/06/2015

03/06/2016

109

1400000000217

RS PELITA ANUGERAH

JL RAYA BANDUNGREJO KM 11.5 MRANGGEN

6725555

LIDIA MEGAWATI

PER/23/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

110

1400000000217

RS PELITA ANUGERAH

JL RAYA BANDUNGREJO KM 11.5 MRANGGEN

6725555

LIDIA MEGAWATI

PER/020/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

111

1500000000210

RS PERMATA BUNDA

JL HAYAM WURUK NO 24 PURWODADI

422838

DR H UTOMO DS SPOG

PER/31/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

112

1400000000219

RS PERMATA MEDIKA

JL MOCH ICHSAN NO 93-97 NGALIYAN

7625005

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

113

1400000000219

RS PERMATA MEDIKA

JL MOCH ICHSAN NO 93-97 NGALIYAN

7625005

PER/019/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

114

1500000000648

RS ROEMANI MUHAMMADIYAH SEMARANG

JL WONODRI 22 SEMARANG

8444623

PROF.DR.DR.H.RIFKI MUSLIM,SPB,SPU

PER/04/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2017

115

1500000000693

RS ST ELISABETH SEMARANG

JL KAWI NO 1 SEMARANG

8310035

YAYASAN RS ST ELISABETH

PER/027/042015

RS.TRAUMA CENTRE

20/04/2015

19/04/2016

116

1500000001247

RS TELOGOREJO

JL KHA DAHLAN SEMARANG

8446000

YAYASASAN KESEHATAN TELOGOREJO

PER/10/052015

RS.TRAUMA CENTRE

19/05/2015

18/05/2017

MA11222I


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200 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

117

1500000000773

RSU WILLIAM BOOTH SEMARANG

JL LETJEND S PARMAN NO 5 SEMARANG

8411800

YAYASAN BALA KESELAMATAN

PER/07/042015

RS.TRAUMA CENTRE

30/04/2015

31/03/2016

118

1500000000222

RSUD DR H SOEWONDO KENDAL

JL LAUT NO.21 KENDAL

381433

DR SRI MULYANI, SP.A, M.KES

PER/025/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2017

119

1500000000222

RSUD DR H SOEWONDO KENDAL

JL LAUT NO.21 KENDAL

381433

DR SRI MULYANI, SP.A, M.KES

PER/27/122015

RS.TRAUMA CENTRE

30/12/2015

31/12/2015

120

1500000000211

RSUD DR R SOEDJATI SOEMODIARDJO

JL DI PANJAITAN 36 PURWODADI

421004

DR BAMBANG PUJIYANTO M.KES

PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

121

1500000000211

RSUD DR R SOEDJATI SOEMODIARDJO

JL DI PANJAITAN 36 PURWODADI

421004

DR BAMBANG PUJIYANTO M.KES

PER/021/022015

RS.TRAUMA CENTRE

16/02/2015

31/12/2015

122

1400000000216

RSUD KOTA SEMARANG

JL FATMAWATI NO 1 SEMARANG

6711500

PER/018/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

123

1400000000216

RSUD KOTA SEMARANG

JL FATMAWATI NO 1 SEMARANG

6711500

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

124

1400000000214

RSUD TUGUREJO

JL. RAYA TUGUREJO KM 9 TAMBAK AJI NGALIYAN

7605297

PER/016/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

125

1400000000214

RSUD TUGUREJO

JL. RAYA TUGUREJO KM 9 TAMBAK AJI NGALIYAN

7605297

PER/27/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

126

7-337195525

RSUP DR KARIADI SEMARANG

JL DR SUTOMO 16 SEMARANG

PER/13/062015

RS.TRAUMA CENTRE

13/11/2015

31/05/2016

KANTOR CABANG

MA11222I

:

50245

024841399 3

KEMENTERIAN KESEHATAN RI

L01- KANTOR CABANG SURAKARTA


SM0480



201 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000142

KLINIK GRIYA HUSADA 1

JL. MEKARSARI RT 03 RW 01 POPONGAN KARANGANYAR

6499639

DR HADIASRI WIDIYASARI

PER/15/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

2

1500000000142


JL. MEKARSARI RT 03 RW 01 POPONGAN KARANGANYAR

6499639

DR HADIASRI WIDIYASARI

PER/14/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

3

1500000000143


SURUH KALONG PANDEYAN TASIKMADU RT 1/ RW 7 KARANGANYAR

9726555

DR ITA KUSUMAWATI

PER/16/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

4

1500000000144


JL SOLO PURWODADI KM 6 GONDANGREJO KARANGANYAR

29726555

CV GRIYA DAYA MANDIRI

PER/17/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

5

1500000001791

KLINIK NAYAKA HUSADA 07 KARANGANYAR

JL RAYA SOLO SRAGEN KM 10 DAWUNG RT 02/01 DESA KEMIRI KEBAKKRAMAT

57171


PER/29/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

6

1500000001791

KLINIK NAYAKA HUSADA 07 KARANGANYAR

JL RAYA SOLO SRAGEN KM 10 DAWUNG RT 02/01 DESA KEMIRI KEBAKKRAMAT

57171


PER/35/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

7

1500000001215

KLINIK NGESTI HUSADA JATI

JL SUMPAH PEMUDA NO. G KADIPIRO

DR DEVI FIKASARI

PER/33/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

8

1500000001215

KLINIK NGESTI HUSADA JATI

JL SUMPAH PEMUDA NO. G KADIPIRO

DR DEVI FIKASARI

PER/27/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

9

1400000000516

KLINIK NGUDI SEHAT

JL. TENTARA PELAJAR NO. 31 SANGGRAHAN GROGOL SUKOHARJO

2974269

SUHADI

PER/18/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

10

1500000000106

KLINIK NGUDI SEHAT PARANGJORO

SINGKIL RT 03 RW 08 PARANGJORO GROGOL SUKOHARJO

2974269


PER/11/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

11

1500000000106


SINGKIL RT 03 RW 08 PARANGJORO GROGOL SUKOHARJO

2974269


PER/10/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

12

1500000000417

KLINIK NURIFA

JL SLAMET RIYADI KARTASURA SUKOHARJO ( KIOS PASAR BUMI REJO )

2601843

DR UMI ARIFAH

PER/22/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

MA11222I


SM0480



202 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

13

1500000000417

KLINIK NURIFA

JL SLAMET RIYADI KARTASURA SUKOHARJO ( KIOS PASAR BUMI REJO )

2601843

14

1100000000030

PUSKESMAS KEBAKKRAMAT

JL RAYA SOLO- SRAGEN KM 12

825812

15

1400000000474

RS DR OEN SOLO BARU

PERUMAHAN SOLO BARU GROGOL

620220

16

1400000000474

RS DR OEN SOLO BARU

PERUMAHAN SOLO BARU GROGOL

17

1100000000033

RS DR OEN SURAKARTA

JL. BRIGJEND KATAMSO 55

18

1500000001866

RS HERMINA SOLO

JL KOL SUTARTO NO. 16 RT 01/02 JEBRES SURAKARTA

19

1500000001866

RS HERMINA SOLO

JL KOL SUTARTO NO. 16 RT 01/02 JEBRES SURAKARTA

20

1100000000034

RS KASIH IBU SURAKARTA

21

1100000000034

22

TIPE IKS

AWAL IKS

AKHIR IKS

PER/24/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

RS DR OEN SOLO BARU

PER/07/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

620220

RS DR OEN SOLO BARU

PER/07/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

643139

YYS PANTI KOSALA

PER/12/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

57116

638989

PT MEDIKA LOKA SOLO

PER/30/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

57116

638989

PT MEDIKA LOKA SOLO

PER/37/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

JL SLAMET RIYADI 404

714422

YYS KASIH IBU

PER/09/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

RS KASIH IBU SURAKARTA

JL SLAMET RIYADI 404

714422

YYS KASIH IBU

PER/08/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

1500000001873

RS KHUSUS BEDAH KARIMA UTAMA SURAKARTA

JL. AMARTA RAYA 8-10 TERMINAL BARU NGABEYAN KARTASURA

783399

PT. KARIMA UTAMA SEJAHTERA

PER/32/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

23

1500000001873

RS KHUSUS BEDAH KARIMA UTAMA SURAKARTA

JL. AMARTA RAYA 8-10 TERMINAL BARU NGABEYAN KARTASURA

783399

PT. KARIMA UTAMA SEJAHTERA

PER/38/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

24

1100000000032

RS KUSTATI

JL KAPT MULYADI 249

643013

PER/09/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

MA11222I

DR UMI ARIFAH


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203 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/10/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

TNI AU SURAKARTA

PER/32/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

RS NIRMALA SURI SUKOHARJO

PER/19/012016

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

714458

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL. JEND A YANI PABELAN

714458

PER/02/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

RS PANTI WALUYO

JL A YANI 1-2

712077

PER/15/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

1100000000031

RS PANTI WALUYO

JL A YANI 1-2

712077

PER/39/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

32

1500000000294

RS PKU MUHAMADIYAH SELOGIRI

JL LAMA NAMBANGAN SELOGIRI WONOGIRI

5327504

YYS PKU MUHAMADIYAH

PER/22/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

33

1500000000294

RS PKU MUHAMADIYAH SELOGIRI

JL LAMA NAMBANGAN SELOGIRI WONOGIRI

5327504

YYS PKU MUHAMADIYAH

PER/21/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

34

1400000000537

RS PKU MUHAMADIYAH SURAKARTA

JL RONGGOWARSITO NO 130 SURAKARTA

714578


PER/20/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

35

1500000001946

RS PKU MUHAMMADIYAH KARANGANYAR

JL PAPAHAN DESA PAPAHAN KECAMATAN TASIKMADU

57171

492685

YAYASAN MUHAMADIYAH

PER/31/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

36

1500000001946

RS PKU MUHAMMADIYAH KARANGANYAR

JL PAPAHAN DESA PAPAHAN KECAMATAN TASIKMADU

57171

492685

YAYASAN MUHAMADIYAH

PER/36/072015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

25

1100000000032

RS KUSTATI

JL KAPT MULYADI 249

643013

26

1500000001009

RS LANUD ADI SOEMARSO

JL TENTARA PELAJAR MALANGJIWAN COLOMADU

780240

27

1400000000536

RS NIRMALA SURI SUKOHARJO

JL SOLO SUKOHARJO KM 9

28

1100000000035

RS ORTHOPEDI PROF DR SOEHARSO

JL. JEND A YANI PABELAN

29

1100000000035

RS ORTHOPEDI PROF DR SOEHARSO

30

1100000000031

31

MA11222I


SM0480



204 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

37

1500000001628

RS PKU MUHAMMADIYAH SRAGEN

JL RAYA SOLO SRAGEN KM 8 MASARAN SRAGEN

YAYASAN MUHAMADIYAH

PER/17/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

38

1500000001628

RS PKU MUHAMMADIYAH SRAGEN

JL RAYA SOLO SRAGEN KM 8 MASARAN SRAGEN

YAYASAN MUHAMADIYAH

PER/28/012016

RS.TRAUMA CENTRE

01/06/2016

31/12/2016

39

08237

RS PKU MUHAMMADIYAH SURAKARTA

JL RONGGOWARSITO SURAKARTA


PER/20/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

40

1500000001531

RSI AMAL SEHAT SRAGEN

JL VETERAN NO 35 SRAGEN

YAYASAN AMAL SEHAT SRAGEN

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

41

1500000001531

RSI AMAL SEHAT SRAGEN

JL VETERAN NO 35 SRAGEN

YAYASAN AMAL SEHAT SRAGEN

PER/25/012016

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

42

7-1689398627

RSO PROF DR R SOEHARSO SURAKARTA

JL A AYANI KARTASURA

KEMENKES

PER/02/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

43

1500000000121

RSU JATI HUSADA KARANGANYAR

JL RAYA SOLO TAWANGMANGU KM 10,3 JATI JATEN KARANGANYAR

PT TENTERAM MAKMUR BERSAMA

PER/11/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

44

1500000000121

RSU JATI HUSADA KARANGANYAR

JL RAYA SOLO TAWANGMANGU KM 10,3 JATI JATEN KARANGANYAR

PT TENTERAM MAKMUR BERSAMA

PER/13/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

45

1500000000687

RSU MARDI LESTARI

JL ROKAN NO 8 SRAGEN

YYS SANTA KATARINA L

PER/24/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

46

1500000000687

RSU MARDI LESTARI



PER/27/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

47

1500000000687

RSU MARDI LESTARI



PER/27/042015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

48

1100000000036

RSUD DR MOEWARDI SURAKARTA

JL KOL SUTARTO 132

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

714578

50771

71445832

634634


SM0480



205 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

49

1100000000036

RSUD DR MOEWARDI SURAKARTA

JL KOL SUTARTO 132

50

1500000000120

RSUD DR SOEHADI PRIJONEGORO SRAGEN

51

1500000000120

52

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/03/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

JL RAYA SUKOWATI 534 SRAGEN

PER/13/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

RSUD DR SOEHADI PRIJONEGORO SRAGEN

JL RAYA SUKOWATI 534 SRAGEN

PER/14/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

1400000000424

RSUD KABUPATEN KARANGANYAR

JL. LAKSDA YOS SUDARSO

495673


PER/04/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

53

1400000000424


JL. LAKSDA YOS SUDARSO

495673


PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

54

1400000000425

RSUD KABUPATEN SUKOHARJO

JL DR MOEWARDI 71 SUKOHARJO

593118


PER/05/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

55

1400000000425


JL DR MOEWARDI 71 SUKOHARJO

593118


PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

56

1400000000423

RSUD KOTA SURAKARTA

JL. LETTU SUMARTO NOMOR : 1 KADIPIRO BANJARSARI

715300

RSUD KOTA SURAKARTA

PER/06/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

57

1400000000423

RSUD KOTA SURAKARTA

JL. LETTU SUMARTO NOMOR : 1 KADIPIRO BANJARSARI

715300

RSUD KOTA SURAKARTA

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

58

1500000000458

RUMAH SAKIT SARILA HUSADA

JL VETERAN NO. 41 - 43 SRAGEN

29697090

RS SARILA HUSADA

PER/25/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

KANTOR CABANG

MA11222I

:

634634

L02- KANTOR CABANG CILACAP


SM0480



206 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001026

KLINIK DAARUSSYIFA

JL. MERPATI NO. 9 RT 02 RW 02 DESA SLARANG KEC KESUGIHAN

5263311

DR TAUFIQ HIDAYAT

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

2

1500000000703

KLINIK GRAHA AMANAH

JL. RAJAWALI NO. 328 RT 03 RW 02 DESA KARANGRENA KEC MAOS

5501687

ARIS NUR RAHMAT

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

3

1500000001675

KLINIK KELUARGA

JL. TENTARA PELAJAR DESA JATINEGARA RT 05 RW 02 KEC SEMPOR

5522836

DR AGUS SAPARIYANTO

PER/20/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

4

1500000000550


JL. KOMPENI NO. 25 PIPA TIMUR

532149


PER/03/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

5

1500000001705

KLINIK PKU MUHAMMADIYAH ADIPALA

JL. BALAI DESA RT 04 RW 05 DESA PENGGALANG KEC ADIPALA

081227126 70

YAYASAN PKU MUHAMMADIYAH

PER/21/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

6

1500000001057

KLINIK PKU MUHAMMADIYAH CILACAP

JL. KUTILANG TIMUR NO. 174 RT 01 RW 05 DESA TEGALREJA KEC. CILACAP SELATAN

521208

YAYASAN PKU MUHAMMADIYAH CILACAP SELATAN

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000001228

KLINIK PKU MUHAMMADIYAH KROYA

JL. RAYA MUJUR - KROYA TROMOL POS 02 KEC. KROYA

494993

YAYASAN PKU MUHAMMADIYAH KROYA

PER/15/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1500000001000

KLINIK PKU MUHAMMADIYAH SAMPANG

JL. RAYA SAMPANG - KARANG TENGAH KM 2 SAMPANG

5265565

PKU MUHAMMADIYAH SAMPANG - CILACAP

PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1500000000865

KLINIK RAJA HUSADA

JL. SRANDIL NO. 212 B RT 006 RW 011 DESA ADIRAJA KEC. ADIPALA

5264443

DR HERI YULIADRI

PER/09/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000000762

RS PALANG BIRU GOMBONG

JL. KARTINI NO. 37 GOMBONG

471290

YAYASAN SWANA SANTA PALANG BIRU GOMBONG KEBUMEN

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1400000000491

RS PKU MUHAMMADIYAH GOMBONG

JL. YOS SUDARSO NO. 461 GOMBONG

471780

DR. IBNU NASER A, S. AG, MMR

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000000866

RS PKU MUHAMMADIYAH SRUWENG

JL. RAYA SRUWENG NO. 5 KEC. SRUWENG

382597

MUHAMMADIYAH CABANG SRUWENG, KEBUMEN

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I

54352

53271


SM0480



207 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000733

RSU PERMATA MEDIKA KEBUMEN

JL. INDRAKILA NO. 17

3870779

DRG. BUDI IRIANTO

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

14

1500000000431

RSU SANTA MARIA CILACAP

JL. JEND. A. YANI NO. 38 KEL. SIDAKAYA KEC. CILACAP SELATAN

521725

YAYASAN MEDIATRIX

PER/02/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

15

1100000000021

RSUD CILACAP

JL GATOT SUBROTO NO. 28

533010

DR. NONO RASINO, SP.OG (K)

PER / 01 / 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

16

1100000000021

RSUD CILACAP

JL GATOT SUBROTO NO. 28

533010

DR. NONO RASINO, SP.OG (K)

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000000702

RSUD MAJENANG

JL. DR. SUTOMO NO. 54 MAJENANG

621012

RSUD MAJENANG

PER/05/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

18

1500000000701

RUMAH SAKIT ISLAM FATIMAH

JL. IR. H. JUANDA NO. 20

542396

YAYASAN RUMAH SAKIT ISLAM

PER/04/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

KANTOR CABANG

NO

KODE PROVIDER

:

L03- KANTOR CABANG YOGYAKARTA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000727

BLKPP DI YOGYAKARTA

JLN KYAI MOJO NO. 5 YOGYAKARTA

512619

DISNAKERTRANS DIY

PER/08/022015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

2

1500000000400

BP PMI DI YOGYAKARTA

JLN RING ROAD BARAT NO. 3, PATHUK, GAMPING, SLEMAN

6499652

PMI PROP DI YOGYAKARTA

PER/03/012016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

3

1500000000400

BP PMI DI YOGYAKARTA

JLN RING ROAD BARAT NO. 3, PATHUK, GAMPING, SLEMAN

6499652

PMI PROP DI YOGYAKARTA

PER/03/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000000173

BP RB CITRA PARAMEDIKA

GRAULAN RT 06 RW 03 GIRIPENI WATES

774876

YAYASAN BINANGUN CITRA PARA MEDIKA

PER/06/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

5

1500000000048

INIK PRATAMA MITRA SEHAT

JL IMOGIRI TIMUR KM 6 DLADAN BARU NGLEBENG TAMANAN BANGUNTAPAN

9103190

CV MITRA SEHAT

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

6

1500000000048

INIK PRATAMA MITRA SEHAT

JL IMOGIRI TIMUR KM 6 DLADAN BARU NGLEBENG TAMANAN BANGUNTAPAN

9103190

CV MITRA SEHAT

PER/50/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

7

1500000001289

KLINIK CHANDRA BRATA MEDIKA PLAZA

TAMBAKAN RT 002 RW 019 SINDUHARJO NGAGLIK

882702

ANDRA BRATA MEDIKA PLAZA

PER/38/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1500000001334

KLINIK HARMONY

GENDENG GK IV/969, BACIRO

DR. ERNA

PER/39/2015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1500000001238

KLINIK HIPERKES DAN KESELAMATAN KERJA

JLN. IREDA NO.38, KEPARAKAN, MERGANGSAN

BALAI HIPERKES

PER/33/062015

RS.TRAUMA CENTRE

01/06/2015

01/05/2016

10

1500000001284

KLINIK LARAS HATI

PRANCAK, GLONDONG, PANGGUNGHARJO, SEWON, BANTUL

RB LARAS HATI

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

1500000001285

KLINIK LARAS HATI KULON PROGO

WONOLOPO RT 33 RW 15, GULUREJO, LENDAH

PER/35/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

12

1500000001160

KLINIK PATALAN

JLN. PARANG TRITIS KM 15, PATALAN, JETIS

DR GLORY

PER/28/052015

RS.TRAUMA CENTRE

28/05/2015

28/05/2016

13

1500000000598

KLINIK PRATAMA ANUGERAH

JLN RINDANG NO. 145, JADAN, TAMANTIRTO, KASIHAN

DR. AR ROYAN

PER/04/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

14

1500000001237

KLINIK PRATAMA KARTIKA HUSADA

TEGALREJO NGLEGIS RT 05. SITIMULYO, BANTUL

PER/34/2015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

15

1500000000062

KLINIK PRATAMA SWA

JL SALAK/TURI KM 4 KADISOBO II RT 02 RW 03 TRIMULYO

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

789670

7485660

YAYASAN SWA YOGYAKARTA


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209 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1500000000062

KLINIK PRATAMA SWA

JL SALAK/TURI KM 4 KADISOBO II RT 02 RW 03 TRIMULYO

7485660

YAYASAN SWA YOGYAKARTA

PER/51/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000000063

KLINIK PRATAMA WIDURI

JL MAGELANG KM 12 WIDORO TRIHARJO SLEMAN

867363

CV WIDURI

PER/53/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

18

1500000000063

KLINIK PRATAMA WIDURI

JL MAGELANG KM 12 WIDORO TRIHARJO SLEMAN

867363

CV WIDURI

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

19

1500000001669

KLINIK UTAMA BEDAH ADELIA

DONOLOYO IA KROBOKAN TAMANAN BANGUNTAPAN

4396680

TRIYONO

PER/40/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

20

1500000001041

PUSEKSMAS PIYUNGAN

PAYAK, SRIMULYO, PIYUNGAN

DINKES BANTUL

PER/23/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

21

1500000001037

PUSKESMAS BAMBANGLIPURO

DAWETAN, SIDOMULYO, BAMBANGLIPURO

DINKES BANTUL

PER/17/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

22

1500000000399

PUSKESMAS BANGUNTAPAN II

KROBOKAN DESA TAMANAN, BANGUNTAPAN , BANTUL

DINKES KAB BANTUL

PER/04/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

23

1500000001042

PUSKESMAS DLINGO I

KORIPAN, DLINGO, BANTUL

DINKES BANTUL

PER/21/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

24

1500000001038

PUSKESMAS IMOGIRI I

NGANCAR, KARANGTALUN, IMOGIRI, BANTUL

DINKES BANTUL

PER/19/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

25

1500000001067

PUSKESMAS JETIS I

TELAN TRIMULY, JETIS BANTUL

DINKES BANTUL

PER/20/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

26

1500000001064

PUSKESMAS KASIHAN I

NGENTAK, BANGUNJIWO, KASIHAAN

DINKES BANTUL

PER/24/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

27

1500000000802

PUSKESMAS KRETEK

JL PARANGTRITIS KM 21, SRUWUH, DONOTIRTO, KRETEK

DINKES KAB BANTUL

PER/11/052015

RS.TRAUMA CENTRE

08/05/2015

07/05/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

28

1500000001049

PUSKESMAS PAJANGAN

BEJI, SENDANGSARI, PAJANGAN, BANTUL

DINKES BANTUL

PER/25/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

29

1500000001063

PUSKESMAS PANDAK I

GESIKAN, WIJIREJO, PANDAK

DINKES BANTUL

PER/18/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

30

1500000001047

PUSKESMAS PLERET

WONOKROMO, PLERET, BANTUL

DINKES BANTUL

PER/22/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

31

1500000001039

PUSKESMAS PUNDONG

PIRING, SRIHARDONO, PUNDONG, BANTUL

DINKES BANTUL

PER/16/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

32

1500000001048

PUSKESMAS SANDEN

PUCANGANOM, MURTIGADING, SANDEN

DINKES BANTUL

PER/15/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

33

1500000001066

PUSKESMAS SEDAYU I

KEMUSUK, ARGOMULYO, SEDAYU

DINKES BANTUL

PER/26/052015

RS.TRAUMA CENTRE

28/05/2015

27/05/2016

34

1500000000803

PUSKESMAS SEWON I

JLN. PARANGTRITIS KM 7, BANGI, TIMBULHARJO, SEWON

DINKES BANTUL

PER/10/052015

RS.TRAUMA CENTRE

08/05/2015

07/05/2016

35

1500000000804

PUSKESMAS SRANDAKAN

JL. RAYA SRANDAKAN, TRIMURTI, SRANDAKAN

DINKES BANTUL

PER/12/052015

RS.TRAUMA CENTRE

08/05/2015

07/05/2016

36

1400000000143

RS CONDONG CATUR

JL MANGGIS NO 6 GEMPOL CONDONG CATUR

887494

DR HERTI ELIZA SILALAHI

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

37

1500000000447

RS ISLAM HIDAYATULLAH

JLN. VETERAN NO. 184, PANDEYAN, UMBULHARJO

389184

PT. RSI HIDAYATULLAH

PER/07/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

38

1400000000142

RS PANTI NUGROHO

JL KALIURANG KM 17

895186

YAYASAN PANTI RAPIH

PER/06/032015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

39

1500000000449

RS PANTI RINI

JLN SOLO KM 13,2 KRAJAN, KALASAN, SLEMAN

496022

YAYASAN PANTI RAPIH

PER/08/03/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

40

1400000000005

RS PKU MUHAMMADIYAH BANTUL

JL. JEND SUDIRMAN NO.124

368238

YAYASAN MUHAMMADIYAH

PER/45/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

41

1400000000005

RS PKU MUHAMMADIYAH BANTUL

JL. JEND SUDIRMAN NO.124

368238


PER/25/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

42

1400000000312

RS PKU MUHAMMADIYAH YOGYAKARTA

JL KHA DAHLAN 20

512653


PER/32/062015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

43

1400000000136

RS QUEEN LATIFA

JL RING ROAD BARAT MLANGI NOGOTIRTO GAMPING

581402

PER/24/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

44

1400000000136

RS QUEEN LATIFA

JL RING ROAD BARAT MLANGI NOGOTIRTO GAMPING

581402

PER/48/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

45

1400000000139

RS RAJAWALI CITRA

JL.PLERET KM 2,5 BANJARDADAP POTORONO BANGUNTAPAN BANTUL

7482003

DR H SUNU PRASMONO

PER/30/062015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

46

1500000001287

RSKIA PKU MUHAMMADIYAH KOTAGEDE

JLN KEMASAN NO.43, PURBAYAN, KOTAGEDE

MUHAMMADIYAH

PER/37/2015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

47

1400000000654

RSPAU DR S HARDJOLUKITO

JALAN RAYA JANTI BLOK O

TNI AU

PER/42/102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

48

1500000001033

RSU AT-TUROST AL-ISLAMY

JLN. KLACI I, MARGOLUWIH, SEYEGAN

YAYASAN MAJELIS ATTUROST AL-ISLAMY

PER/27/052015

RS.TRAUMA CENTRE

18/05/2015

18/04/2016

49

1400000000478

RSU BHAYANGKARA POLDA DI YOGYAKARTA

JL JOGYA-SOLO KM 14 GLONDONG TIRTOMARTANI KALASAN

498278

POLDA DI YOGYAKARTA

PER/44/122015

RS.TRAUMA CENTRE

18/01/2016

30/11/2016

50

1500000000812

RSU GRIYA MAHARDIKA YOGYAKARTA

JLN. PARANGTRITIS KM 4,5 GG. WIJAYAKUSUMA NO. 212, SEWON

445020

PT. RSGM

PER/13/05/2015

RS.TRAUMA CENTRE

18/05/2015

17/05/2016

51

1400000000138

RSU KAB SLEMAN

JL BHAYANGKARA 48 MORANGAN SLEMAN

868437

PEMKAB BANTUL

PER/41/062015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

444715


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

52

1500000000168

RSU KHARISMA PARAMEDIKA

JL KHUDORI NO. 34 WATES

774633

YAYASAN BINANGUN KHARISMA PARAMEDIKA

PER/05/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

53

1500000000169

RSU MITRA SEHAT

JL WATES KM. 9 BALECATUR GAMPING

6498555

PT EMPAT MITRA

PER/07/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

54

1500000000349

RSU PURI HUSADA

JLN PALAGAN TENTARA PELAJAR KM 11 NO.67 SARIHARJO, NGAGLIK

867270

PT. HUSADA EDUKA HOLISTIKA

PER/02/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

55

1500000000349

RSU PURI HUSADA

JLN PALAGAN TENTARA PELAJAR KM 11 NO.67 SARIHARJO, NGAGLIK

867270

PT. HUSADA EDUKA HOLISTIKA

PER/02/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

56

1500000000858

RSU RACHMA HUSADA

JLN PARANG TRITIS KM 16, PATALAN, JETIS, BANTUL

YAYASAN BINA MITRA HUSADA

PER/14/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

57

1500000000327

RSUD KOTA YOGYAKARTA

JL WIROSABAN NO.1 YOGYAKARTA

371195

PEMKOT YOGYAKARTA

PER/01/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

58

1500000000327

RSUD KOTA YOGYAKARTA

JL WIROSABAN NO.1 YOGYAKARTA

371195

PEMKOT YOGYAKARTA

PER/04/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

59

1400000000475

RSUD WATES

JL TENTARA PELAJAR KM 1 NO 5

773169

PEMDA KULON PROGO

PER/43/122015

RS.TRAUMA CENTRE

18/01/2016

31/10/2016

60

1500000000586

RSUP DR SARDJITO

JLN KESEHATAN NO. 1, SEKIP, SINDUADI

587333

KEMENKES

PER/09/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

61

1400000000479

RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAH MADA

JL KABUPATEN KRONGGAHAN TRIHANGGO GAMPING

4530404

UNIVERSITAS GADJAH MADA

PER/49/122015

RS.TRAUMA CENTRE

18/01/2016

30/11/2016

62

1400000000315

RUMAH SAKIT ISLAM YOGYAKARTA PDHI

JL SOLO KM 12,5 KALASAN SLEMAN

498000

PROF.DR.DR.H LAMSUDIN

PER/22/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

63

1400000000315

RUMAH SAKIT ISLAM YOGYAKARTA PDHI

JL SOLO KM 12,5 KALASAN SLEMAN

498000

PROF.DR.DR.H LAMSUDIN

PER/47/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

64

1400000000480

RUMAH SAKIT LUDIRA HUSADA TAMA

JL WIRATAMA NO. 4 TEGALREJO

620333

DR BONDAN AGUS SURYANTO

PER/46/122015

RS.TRAUMA CENTRE

18/01/2016

30/11/2016

65

1400000000695

RUMAH SAKIT NUR ROHMAH

JL WONOSARI-YOGYA KM 7 BANDUNG PLAYEN

394574

PT.RAHMA BAKTI HUSADA

PER/23/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

66

1400000000695

RUMAH SAKIT NUR ROHMAH

JL WONOSARI-YOGYA KM 7 BANDUNG PLAYEN

394574

PT.RAHMA BAKTI HUSADA

PER/54/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

67

1400000000696

RUMAH SAKIT PANTI RAHAYU

JALAN WONOSARI-PONJONG KM 7 KELOR KARANGMOJO

392718

YAYASAN PANTI RAPIH

PER/21/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

68

1400000000696

RUMAH SAKIT PANTI RAHAYU

JALAN WONOSARI-PONJONG KM 7 KELOR KARANGMOJO

392718

YAYASAN PANTI RAPIH

PER/52/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

69

1400000000134

RUMAH SAKIT PANTI RAPIH

JALAN CIK DI TIRO NO 30

514014

YAYASAN PANTI RAPIH

PER/32/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

L04- KANTOR CABANG PEKALONGAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

1

1500000001803

KLINIK PRATAMA MARDLATILLAH

JL RAYA PEMALANG RANDUDONGKAL

52361

2

1500000001805

RS BUDI RAHAYU

JL BARITO NO 5

51113

423491

3

1500000001799

RS MUHAMMADIYAH RODLIYAH ACHID MOGA

JL RAYA MOGA PULOSARI KM 2 MOGA

52315

86267099

MA11222I

PIMPINAN

PD MUHAMMADIYAH KABUPATEN PEMALANG

PD MUHAMMADIYAH PEMALANG

TIPE IKS

AWAL IKS

AKHIR IKS

PER / 015 / 062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PER / 08 / 052015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PER / 014 / 062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016


SM0480



214 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1400000000411

RS QOLBU INSAN MULIA (QIM)

JL URIP SUMOHARJO - SAMBONG

51211

4495222

PT QOLBU INSAN MULIA

PER / 24 /112015

RS.TRAUMA CENTRE

01/11/2015

31/10/2016

5

1500000001804

RS SITI KHODIJAH

JL BANDUNG NO 39 SUGIH WARAS

51111

422845

YAYASAN AL IRSYAD AL ISLAMIYYAH

PER / 017 / 062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

6

1500000001239

RSU ARO

JL DR SOETOMO GAMER

4416443

DR BROTO RAHARDJO

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000001240

RSU KAROMAH HOLISTIC

JL GADJAHMADA BARAT NO.124

420218

DR. ASTRID WIDYASTUTI

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1400000000008

RSU SANTA MARIA PEMALANG

JL PEMUDA NO 24

321251

DR WIDODO YULIANTO,MKES M

PER/09/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1500000001214

RSUD BENDAN

JL SRIWIJAYA NO 2

437232

DR BAMBANG PRASETIJO

PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000001806

RUMAH SAKIT H.A. DJUNAID

JL PELITA II BUARAN PEKALONGAN

PER / 016 / 062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

KANTOR CABANG

NO

KODE PROVIDER

:

L05- KANTOR CABANG KUDUS

NAMA PROVIDER

ALAMAT

1

1500000001992

KLINIK PRATAMA AMAL SEHAT

JL DESA SADANG RT 04/04 JEULO

2

1500000000942

KLINIK PRATAMA ANUGERAH HEXA

JL JEPARA KM 3 TERSONO GARUNG LOR KALIWUNGU

MA11222I

51117

KODE POS

59316

IKS TELEPON

PIMPINAN NO IKS

437376

TIPE IKS

AWAL IKS

AKHIR IKS

DR MUSTIKO WIBOWO

PER/29/X/2015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

DR ANWAR RIYANTO

PER/015/052015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016


SM0480



215 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

3

1500000001995

KLINIK PRATAMA BINA MEDICA

JL. KUDUS PURWODADI KM 8 UNDAAN LOR

4

1500000001666

KLINIK PRATAMA CAHAYA HUSADA

5

1500000000943

6

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

42427610

FAQIH, SKM

PER/033/X/2015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

JL GETAS PEJATEN RT 01 RW03 JATI

325784324

DR BOBY HADI SARHASTANTO

PER/018/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KLINIK PRATAMA MASYITHOH

JL KYAI TELINGSING 51 SUNGGINGAN

440543

BP MASYITHOH

PER/019/052015

RS.TRAUMA CENTRE

04/05/2015

30/04/2016

1500000001989


JL. PATIMURA RT 05/01 LORAM KULON

59318

4246276

DR HARIYANTO

PER/032/X/2015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

7

7-1073301393

KLINIK PRATAMA SEJAHTERA

JL RA KARTINI NO 15 PATI

59111

DR JOKO MARDIYANTO

PER.030/X/2015

RS.TRAUMA CENTRE

07/01/2016

30/09/2016

8

1500000001991

KLINIK PRATAMA SURYA MEDIKA

JL.SURYO KUSOMO NO,337 MEJOBO RT 03/02 MEJOBO

59318

7437747

DR CHUSNUL KHOTIMAH

PER/33/X/2015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

9

1500000000641

POLIKLINIK YASIN MEDIKA

JL SOEKARNO HATTA KM 4.8 RT 7/8 TAHUNAN

727047406

DINY NOOR KHAYATI

PER/13/04215

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

10

1500000000947

RS GRAHA HUSADA JEPARA

JL MH THAMRIN NO 14 PANGGANG

597807

DR HENY DYAH LISIANA

PER/017/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1500000001985

RS KARTIKA HUSADA KUDUS

JL JEND SUDIRMAN NO.64

432532

RS KARTIKA HUSADA

PER/0026/10201 5

RS.TRAUMA CENTRE

01/10/2015

30/09/2017

12

1500000000334

RS MARDIRAHAYU KUDUS

JL AKBP AGIL KUSUMADYA 110

434707

RS MARDIRAHAYU

PER/004/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

13

1500000001178

RS MITRA BANGSA

JL KOLONEL SUGIONO NO 75

382555

YAYASAN WALI SONGO

PER/28/052015

RS.TRAUMA CENTRE

04/05/2015

30/06/2016

14

1500000001386

RS NURUSSYIFA KUDUS

JL RAYA KUDUS PATI KM 10

4246440

RS NURUSSYIFA

PER/020/052015

RS.TRAUMA CENTRE

04/05/2015

30/04/2017

MA11222I

59316

59317


SM0480



216 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/014/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

RS PKU MUHAMMADIYAH

PER/009/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

532257

RS PKU MUHAMMADIYAH

PER/022/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JL. RAYA TAYU PATI KM 3 PAKIS

4150645

DR INDAH RESTIYANTI

PER/018/052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

RS UMUM DAERAH KABUPATEN KUDUS

JL. LUKMONOHADI NO 19 KUDUS

444001

RSUD KAB KUDUS

PER/008/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2016

1500000000335

RSI ARAFAH REMBANG

JL RAYA REMBANG LASEM KM5 TRITUNGGAL

531666

RSI ARAFAH REMBANG

PER/10/032015

RS.TRAUMA CENTRE

01/03/2015

31/03/2016

21

1500000000642

RSI ISLAM PATI

JL RAYA PATI TAYU KM 18 DS WATUROYO MARGOYOSO

YKM NU

PER/011/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

22

1500000000138

RSI SULTAN HADLIRIN JEPARA

JL RAYA JEPARA BANGSRI KM 3 DS KUWASEN

591507


PER/003/012016

RS.TRAUMA CENTRE

02/02/2016

31/12/2017

23

1500000000138


JL RAYA JEPARA BANGSRI KM 3 DS KUWASEN

591507


PER/003/01/2015

RS.TRAUMA CENTRE

20/01/2015

20/01/2016

24

05896

RSK MARDI RAHAYU

JL AKBP R AGIL KUSUMADYA NO 110 KUDUS

434707

YAYASAN KRISTEN KESEJAHTERAAN MARDI RAHAYU

1482/DIR/PKS/I/ 2016

RS.TRAUMA CENTRE

19/01/2016

01/12/2016

25

05896

RSK MARDI RAHAYU

JL AKBP R AGIL KUSUMADYA NO 110 KUDUS

434707

YAYASAN KRISTEN KESEJAHTERAAN MARDI RAHAYU

PER/001/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

26

1500000000164

RSU DR R SOETIJONO BLORA

JL DR SUTOMO NO 42

531118

RSU DR R SOETIJONO

PER/004/012016

RS.TRAUMA CENTRE

02/02/2016

31/12/2017

15

1500000000661

RS PERMATA

JL REKSODIPURO NO 57

531624

16

1500000001387

RS PKU MUHAMADIYAH MAYONG

JL RAYA NO.12 MAYONG LOR JEPARA

4256500

17

1500000001678

RS PKU MUHAMMADIYAH BLORA

JL RAYA CEPU KM 3 BLORA

18

1500000001389

RS SEBENING KASIH PATI

19

1400000000314

20

MA11222I

58217


SM0480



217 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

27

1500000000164

RSU DR R SOETIJONO BLORA

JL DR SUTOMO NO 42

531118

RSU DR R SOETIJONO

PER/001/012015

RS.TRAUMA CENTRE

12/01/2015

31/12/2015

28

1500000001667

RSU FASTABIQ SEHAT PKU MUHAMMADIYAH

JL. RAYA TAYU KM 3 TAMBAH HARJO

4199008

DR ARDILLA S

PER/021/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

29

1400000000465

RSUD DOKTER R SOETRASNO REMBANG

JL. PAHLAWAN NO.16

691444

RSUD DOKTER R SOETRASNO REMBANG

PER/027/092015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

30

7-1061786476

RSUD DR LOEKMONO HADI KUDUS

JL DR LOEKMONO HADI NO 19 KUDUS

59319

029144400 1

PEMERINTAH DAERAH

440/327/23.01.01 /2015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

31

1500000001986

RSUD DR R SOEPRAPTO CEPU

JLN RONGGOLAWE NO 50 CEPU

58218

421026

RSUD DR SEPRAPTO CEPU

PER/0026/08201 5

RS.TRAUMA CENTRE

01/08/2015

31/07/2016

32

7-1511265053

RSUD KELET

JL RAYA KELET KM 33 JEPARA

59454

DR WIDYO KUNTO M KES MRS

910/1448.B/X/20 15

RS.TRAUMA CENTRE

20/01/2016

31/10/2017

33

1400000000558

RSUD RA KARTINI KABUPATEN JEPARA

JL. WACHID HASYIM NO.100

591175

RSUD JEPARA

PER/004/01/2015

RS.TRAUMA CENTRE

12/01/2015

31/01/2016

34

1400000000249

RSUD RAA DR SOEWONDO KAB PATI

JL.DR SUSANTO NO.114

381102

445/31/062014

RS.TRAUMA CENTRE

01/06/2015

35

7-1601479543

RSUD RAA SOEWONDO PATI

JL.DR. SUSANTO NO. 114 PATI

DR. SUWORO NURCAHYONO.M.KES

PER/009/012016

RS.TRAUMA CENTRE

26/01/2016

31/12/2016

36

1500000000944

RUMAH SAKIT BUDI AGUNG

JL. BAJO NO.7 JUWANA

471321

PRATOMO WIDODO

PER/016/052015

RS.TRAUMA CENTRE

04/05/2015

30/04/2016

37

1400000000427

RUMAH SAKIT ISLAM SUNAN KUDUS

JL.KUDUS PERMAI NO1

432008

RUMAH SAKIT ISLAM SUNAN KUDUS

PER/028/092015

RS.TRAUMA CENTRE

01/10/2015

30/09/2017

38

7-1061786478

RUMAH SAKIT KELUARGA SEHAT

JL P SUDIRMAN NO 9 MARGOREJO PATI

295386111

SWASTA

8784/KSH/PKS/ XI/2015

RS.TRAUMA CENTRE

12/01/2016

01/09/2017

MA11222I

59163

59163


SM0480



218 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

39

1500000000137

RUMAH SAKIT KUMALASIWI KUDUS

JL JEPARA KM 6 DESA MIJEN RT 10 RW 06 KALIWUNGU

4245551


PER/005/2016

RS.TRAUMA CENTRE

02/02/2016

31/12/2017

40

1500000000137


JL JEPARA KM 6 DESA MIJEN RT 10 RW 06 KALIWUNGU

4245551


PER/002/01/2015

RS.TRAUMA CENTRE

21/01/2015

31/12/2015

41

7-1534312103

RUMAH SAKIT MARDI RAHAYU KUDUS

JL AKBP R AGIL KUSUMADYA KUDUS

59346

DR KHRISNA NUGRAHA W

PER/001/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

42

7-1534989054

RUMAH SAKIT UMUM DAERAH KELET

JL RAYA KELET KM 33 JEPARA

59431

DR WIDYO KUNTO M.KES MRS

PER/0035/11201 5

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

43

1500000001668

RUMKITBAN 84.08.05 BLORA

JL DR SOETOMO NO.45

RUMKITBAN.84.08.05 BLORA

PER/023/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

L06- KANTOR CABANG MAGELANG

NAMA PROVIDER

ALAMAT

1

1500000001889

KLINIK PRATAMA BRASTOMOLO

JL TENTARA GENIE PELAJAR PERUM MADURESO ASRI RT 06/04 MADURESO TEMANGGUNG

2

08355

RS PKU MUHAMMADIYAH PURWOREJO

3

1500000000112

4

1500000000112

MA11222I

22898046

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

713656429

SUPARJA

PER/09/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

JL BRIGJEN KATAMSO NO 144A

325260

YAYASAN RSU PKU MUHAMMADIYAH

PER/10/072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

RS PKU MUHAMMADIYAH TEMANGGUNG

JALAN RAYA KEDU KM 2 KALISAT CAMPURSARI BULU TEMANGGUNG

596704

PIMPINAN DAERAH MUHAMMADIYAH TEMANGGUNG

PER/20/122014

RS.TRAUMA CENTRE

01/07/2015

31/10/2015

RS PKU MUHAMMADIYAH TEMANGGUNG

JALAN RAYA KEDU KM 2 KALISAT CAMPURSARI BULU TEMANGGUNG

596704

PIMPINAN DAERAH MUHAMMADIYAH TEMANGGUNG

PER/20/122014

RS.TRAUMA CENTRE

01/11/2015

31/12/2015

56229


SM0480



219 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

368950

YAYASAN KESEJAHTERAAN ISLAM KOTA MAGELANG

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

JL. PAHLAWAN PARAKAN TEMANGGUNG

596008

YAYASAN YAKKUM

PER/05/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

RST DR SOEDJONO

JL URIP SUMOHARJO NO 48

362813

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

1500000001874

RSU PANTI WALUYO PURWOREJO

JL. AHMAD YANI NO 21 PURWOREJO

9

1400000000467

RSU PKU MUHAMMADIYAH PURWOREJO

10

1400000000467

11

5

1500000001798

RSI KOTA MAGELANG

JL. JERUK NO 4A KOTA MAGELANG

6

1500000001234

RSK NGESTI WALUYO

7

1400000000020

8

56115

322096

YAYASAN KRISTEN UNTUK KESEHATAN UMUM

PER/08/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

JL BRIGJEN KATAMSO NO 144A RT 1 RW 5 PANGENREJO PURWOREJO

325260


PER/18/112014

RS.TRAUMA CENTRE

01/07/2015

31/10/2015

RSU PKU MUHAMMADIYAH PURWOREJO

JL BRIGJEN KATAMSO NO 144A RT 1 RW 5 PANGENREJO PURWOREJO

325260


PER/18/112014

RS.TRAUMA CENTRE

01/11/2015

31/12/2015

7-1712506763

RSUD DR TJITROWARDOJO PURWOREJO

JL. JENDERAL SUDIRMAN NO. 60 PURWOREJO

275321118

RSUD DR TJITROWARDOJO PURWOREJO

PER/01/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2017

12

1400000000023

RSUD KABUPATEN TEMANGGUNG

JL DR SUTOMO NO 67

491119

PER/17/112014

RS.TRAUMA CENTRE

01/07/2015

31/10/2015

13

1400000000023

RSUD KABUPATEN TEMANGGUNG

JL DR SUTOMO NO 67

491119

PER/17/112014

RS.TRAUMA CENTRE

01/11/2015

31/12/2015

14

1400000000021

RSUD SETJONEGORO WONOSOBO

JL RUMAH SAKIT NO 1

321091

PER/24/122014

RS.TRAUMA CENTRE

01/11/2015

31/12/2015

15

1400000000452

RUMAH SAKIT AISYIYAH MUNTILAN

JL KH.A DAHLAN NO 24 MUNTILAN

587372

PIMPINAN PUSAT MUHAMMADIYAH

PER/14/102014

RS.TRAUMA CENTRE

01/07/2015

31/10/2015

16

1400000000452

RUMAH SAKIT AISYIYAH MUNTILAN

JL KH.A DAHLAN NO 24 MUNTILAN

587372

PIMPINAN PUSAT MUHAMMADIYAH

PER/14/102014

RS.TRAUMA CENTRE

01/11/2015

31/12/2015

MA11222I

54112

54114


SM0480



220 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1500000000113

RUMAH SAKIT ISLAM WONOSOBO

JL MAYJEN BAMBANG SUGENG KM 03 MENDOLO BUMIRESO

322961

YAYASAN AMAL DAN KESEJAHTERAAN UMAT ISLAM (YAKAUMI)

PER/02/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2017

18

1500000000113



322961


PER/01/012015

RS.TRAUMA CENTRE

29/01/2016

31/12/2015

19

1500000000113



322961


PER/01/012015

RS.TRAUMA CENTRE

01/07/2015

31/10/2015

20

1500000000113



322961


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

30/06/2015

KANTOR CABANG

NO

KODE PROVIDER

:

L07- KANTOR CABANG TEGAL

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001580

KLINIK AZ-ZAHRA

JL RAYA LEBAKSIU RT 02/03 LEBAKSIU LOR

DR M KARIM AMRULLAH

PER/09/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

2

1500000001580

KLINIK AZ-ZAHRA

JL RAYA LEBAKSIU RT 02/03 LEBAKSIU LOR

DR M KARIM AMRULLAH

PER/09/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1500000001579

KLINIK KS TUBUN 81

JL KS TUBUN NO 81 RT 01/01 KEL DEBONGTENGAH

081828983 6

DR SUHARJO

PER/10/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1500000001579

KLINIK KS TUBUN 81

JL KS TUBUN NO 81 RT 01/01 KEL DEBONGTENGAH

081828983 6

DR SUHARJO

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

5

1500000001755

KLINIK SEJAHTERA 1

DESA TEMBOK LOR RT 10/02 KEC ADIWERNA

7608142

DR NAJMUL IMAN

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I

52194


SM0480



221 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6

1500000001755

KLINIK SEJAHTERA 1

DESA TEMBOK LOR RT 10/02 KEC ADIWERNA

52194

7608142

DR NAJMUL IMAN

PER/12/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7

1500000001756

KLINIK SEJAHTERA 2

DESA HARJOSARI KIDUL RT 24/06 KEC ADIWERNA

52194

7608142

DR NAJMUL IMAN

PER/13/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1500000001756

KLINIK SEJAHTERA 2

DESA HARJOSARI KIDUL RT 24/06 KEC ADIWERNA

52194

7608142

DR NAJMUL IMAN

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

9

1200000000015

RS BHAKTI ASIH BREBES (TC)

JL P DIPONEGORO PESANTUNAN 125 BREBES

673481

DR KHOSIATUN AZMI

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

10

1200000000015

RS BHAKTI ASIH BREBES (TC)

JL P DIPONEGORO PESANTUNAN 125 BREBES

673481

DR KHOSIATUN AZMI

PER/05/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

0900000000036

RS DEDY JAYA (TC)

JL AHMAD YANI NO 57

672525

DR IRMA YURITA

PER/02/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

12

0900000000036

RS DEDY JAYA (TC)

JL AHMAD YANI NO 57

672525

DR IRMA YURITA

PER/02/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000000186

RS MITRA SIAGA

JL PALA RAYA NO 54 KEC KRAMAT

322550

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

14

1500000000186

RS MITRA SIAGA

JL PALA RAYA NO 54 KEC KRAMAT

322550

PER/01/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

1000000000009

RSI PKU MUHAMMADIYAH KABUPATEN TEGAL(TC)

JALAN RAYA SINGKIL KM 0.5 ADIWERNA

3448180

DR H. ACHMAD SHOCHIBUL BIRRI

PER/06/012015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

16

1000000000009

RSI PKU MUHAMMADIYAH KABUPATEN TEGAL(TC)

JALAN RAYA SINGKIL KM 0.5 ADIWERNA

3448180

DR H. ACHMAD SHOCHIBUL BIRRI

PER/06/012015

RS.TRAUMA CENTRE

01/07/2015

17

1500000001754

RSU ADELLA

JL PROF MOH YAMIN NO 77 KEL KUDAILE KEC SLAWI

491154

DR H M ABDUL DJALIL MKES

PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

MA11222I

52419


31/12/2015

SM0480



222 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

18

1500000001754

RSU ADELLA

JL PROF MOH YAMIN NO 77 KEL KUDAILE KEC SLAWI

19

01626

RSU KARDINAH TEGAL

JL KS TUBUN NO. 1 TEGAL

20

0800000000030

RSU SITI ASIYAH

JL PASAR WAGE BUMIAYU

41059007

21

0900000000035

RSUD DR SOESELO SLAWI (TC)

JL DR SUTOMO NO 63 SLAWI

22

0900000000035

RSUD DR SOESELO SLAWI (TC)

JL DR SUTOMO NO 63 SLAWI

23

7-1033158771

RSUD KARDINAH TEGAL

JL KS TUBUN KOTA TEGAL

24

1500000001236

RSUD SURADADI

JL RAYA TEGAL-PEMALANG KM.12 SURADADI

25

1500000001236

RSUD SURADADI

26

0900000000029

27

0900000000029

KANTOR CABANG

MA11222I

:

PIMPINAN AWAL IKS

AKHIR IKS

PER/11/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PER/14/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

DR H FAISAL AMRI, SH

PER/07/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

491991

DR WIDODO JOKO MULYONO, M,KES,MMR

PER/04/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

491991

DR WIDODO JOKO MULYONO, M,KES,MMR

PER/04/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

PEMKOT TEGAL

PER/14/112015

RS.TRAUMA CENTRE

17/12/2015

31/12/2016

3336263

PEMERINTAH KABUPATEN TEGAL

PER/08/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

JL RAYA TEGAL-PEMALANG KM.12 SURADADI

3336263

PEMERINTAH KABUPATEN TEGAL

PER/08/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

RSUI HARAPAN ANDA (TC)

JL ABABIL NO 42

353387

HABIYAH. MMR

PER/03/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

RSUI HARAPAN ANDA (TC)

JL ABABIL NO 42

353387

HABIYAH. MMR

PER/03/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

52419

491154

52122

DR H M ABDUL DJALIL MKES

TIPE IKS

L08- KANTOR CABANG KLATEN


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223 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

JL. RAYA BOYOLALI SELO KM 5 JELOK CEPOGO

081393306 461

7-1549815415

KLINIK NAYAKA HUSADA 02 BOYOLALI

DK. BUTUH MOJOSONGO BOYOLALI

024760562 1

3

1500000000102

KLINIK PKU MUH JATINOM

JL RAYA JATINOM KLATEN KM 1 KLATEN

337334

4

1500000000102



337334

5

1500000000102



337334

6

1500000000688

KLINIK PKU MUHAMMADIYAH CAWAS

JL CAWAS PEDAN BELAKANG POLSEK CAWAS KLATEN

897661

7

1500000000444

KLINIK PKU MUHAMMADIYAH POLAN HARJO

JL COKRO DELANGGU GUDANG ABANG WANGEN POLANHARJO

557002

8

1500000001520

KLINIK PRATAMA PMI KABUPATEN BOYOLALI

JL RANDU ASRI KP KOPLAK SISWODIPURAN

3283734

9

1500000000083

KLINIK PRATAMA RAWAT INAP MILA HUSADA

JL . RAYA PENGGING KM 02 BANYUDONO BOYOLALI

10

1500000000083

KLINIK PRATAMA RAWAT INAP MILA HUSADA

JL . RAYA PENGGING KM 02 BANYUDONO BOYOLALI

11

1500000001869

KLINIK PRATAMA RAWAT INAP REJOSARI HUSADA

JL DELANGGU POLANHARJO NO 41 REJOSARI SABRANG

12

1500000000293

KLINIK UPK PMI KLATEN

JL. VETERAN NO 80 KLATEN UTARA

1

1400000000435

KLINIK INSAN SEHAT

2

MA11222I

57322

57411

PIMPINAN TIPE IKS

AWAL IKS

AKHIR IKS

PER/24/112015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

PER/07/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

YAYASAN MUHAMMADIYAH CAB JATINOM KLATEN

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

YAYASAN MUHAMMADIYAH CAB JATINOM KLATEN

PER/06/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/05/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PMI KAB BOYOLALI

PER/15/062015

RS.TRAUMA CENTRE

22/06/2015

21/05/2016

327453

DR. H DIDIK SUPRAPTO

PER/05/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

327453

DR. H DIDIK SUPRAPTO

PER/01/JKK/012 015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

552215

PT PRABAWATAMA INDONESIA

PER/17/072015

RS.TRAUMA CENTRE

23/07/2015

22/06/2016

8850400

DR TRI ARI SUSANTO

PER/03/032015

RS.TRAUMA CENTRE

02/03/2015

29/02/2016

PT RESTU BUNDA YAYASAN DANA PENSIUN KARYAWAN BPJS KETENAGAKERJAAN YAYASAN MUHAMMADIYAH CAB JATINOM KLATEN

YAYASAN MUHAMMADIYAH CABANG CAWAS PIMPINAN CABANG MUHAMMADIYAH POLANHARJO KABUPATEN KLATEN


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1400000000147

RS HIDAYAH BOYOLALI

KRAGILAN MOJOSONGO BOYOLALI

324614

YAYASAN DUA SEPTEMBER BOYOLALI

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

1500000001975

RS ISLAM BANYU BENING

JL RAYA WADUK CENGKLIK NGARGOREJO NGEMPLAK BYL

7910812

YAYASAN RS ISLAM BANYUBENING

PER/22/102015

RS.TRAUMA CENTRE

12/10/2015

11/09/2016

15

1500000000445

RS KARANGGEDE SISMA MEDIKA

JL RAYA KARENGGEDE SOLO KM 1 KEBONAN KARANGGEDE BOYOLALI

610600

PT SISMADI MEDCORPINDO BOYOLALI

PER/06/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

16

0800000000001

RSI KLATEN

JL YOGYA-SOLO KETANDAN KLATEN

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

0800000000001

RSI KLATEN

JL YOGYA-SOLO KETANDAN KLATEN

PER/18/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

18

1500000000292

RSU ASY SYIFA SAMBI BOYOLALI

JL RAYA BANGAK SIMO KM 7 SAMBI BOYOLALI

YAYASAN KARTIKA HUSADA SAMBI

PER/04/032015

RS.TRAUMA CENTRE

02/03/2015

29/02/2016

19

7-1550676406

RSU CAKRA HUSADA KLATEN

JL. MERBABU NO 7

PT CAKRA HUSADA

PER/08/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

20

0800000000004

RSU PANDAN ARANG BOYOLALI

JL KANTIL 14 BOYOLALI

PER/19/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

21

0800000000004

RSU PANDAN ARANG BOYOLALI

JL KANTIL 14 BOYOLALI

PER/02/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

22

1100000000010

RSU PKU AISYIYAH BOYOLALI

JL. PASAR SAPI BARU SINGKILKARANGGENENG BOYOLALI

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

23

0800000000002

RSU SOERADJI TIRTONEGORO

JL SURADJI TIRTONEGORO

PER/04/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

24

0800000000002

RSU SOERADJI TIRTONEGORO

JL SURADJI TIRTONEGORO

PER/218/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

MA11222I

3294459

57412

322898


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

0800000000005

RSUD BANYUDONO

JL RAYA SOLO-SEMARANG

085647136 655

PEMDA

PER/03/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

26

0800000000005

RSUD BANYUDONO

JL RAYA SOLO-SEMARANG

085647136 655

PEMDA

PER/20/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

27

1400000000253

RUMAH SAKIT PKU MUHAMMADIYAH DELANGGU

JL RAYA DELANGGU UTARA NO 19 DELANGGU KLATEN

551051

YAYASAN MUHAMMADIYAH CABANG DELANGGU

PER/16/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

KANTOR CABANG

NO

KODE PROVIDER

:

L09- KANTOR CABANG PURWOKERTO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000603

BKMM KABUPATEN BANYUMAS

JL JEND SUDIRMAN PURWOKERTO

635602

PER/18/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

2

1400000000575

BP PMI PURBALINGGA

JL LETKOL ISDIMAN NO 116 PURBALINGGA

891359

PER/36/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

3

1500000000627

KLINIK ANASTASIA

GEMURUH RT 5/1 BAWANG

BAMBANG WP

PER/20/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

4

1500000000418

KLINIK KURNIA

JL RAYA SAMPANG KM 4 BUNTU KALIWEDI KEBASEN

5295250

YAYASAN IMAM CHALIFAH

PER/09/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

5

1400000000571

KLINIK PKU MUHAMMADIYAH PURBALINGGA

JL KOL SUGIRI GANDASULI BOBOTSARI

758808

PDM PURBALINGGA

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

6

1500000000629

KLINIK PMI BANYUMAS

JL ADYAKSA NO 8 PURWOKERTO

636842

PMI BANYUMAS

PER/23/052015

RS.TRAUMA CENTRE

01/05/2015

31/05/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/10/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

PER/12/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

SUHARNO

PER/15/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

6440963

YYS SOSIAL BINA SEJAHTERA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

53353

758678

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

JL. RAYA BOJONG NO. 130 PURBALINGGA

53362

895680

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

PUSKESMAS BOJONGSARI (PURBALINGGA)

JL. RAYA BOJONGSARI 28 KEC. BOJONGSARI PURBALINGGA

53362

6596981

DR. NONOT MULYNO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

1500000001696

PUSKESMAS BUKATEJA (PURBALINGGA)

JL.ARGANDARU NO.1 KEC BUKATEJA PURBALINGGA RT 4 RW 1

53382

476050

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

15

1500000001695

PUSKESMAS KALIGONDANG (PURBALINGGA)

JL. RAYA SELAKAMBANG KALIGONDANG PURBALINGGA

53331

7057884

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

16

1500000001697

PUSKESMAS KALIKAJAR (PURBALINGGA)

JL. SELAKAMBANG KM. 2,5 NO. 01 KALIAKAJAR PURBALINGGA

53331

893379

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

17

1500000001686

PUSKESMAS KALIMANAH (PURBALINGGA)

JL. MAYJEND. SUNGKONO 39 KEC. KALIMANAH PURBALINGGA

53371

892414

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

18

1500000001688

PUSKESMAS KARANGANYAR (PURBALINGGA)

JL.RY KARANGANYAR /KERTANEGARA NO.3 PURBALINGGA RT 02 RW 1

7632913

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

7

1500000000117

KLINIK SEHAT AMANAH

JL INPRES NO 20 TAMBAKSARI

8

1500000000626

KLINIK UMP

JL RAYA DUKUHWALUH KEMBARAN

9

1500000000351

KLINIK UTAMA AMANDA PURWOKERTO

JL MARTADIREJA II NO 32 PURWOKERTO

642484

10

1500000001090

KLINIK YOS SUDARSO

JL SIDODADI 2/7 SOKARAJA BANYUMAS

11

1500000001700

PUSKESMAS BOBOTSARI (PURBALINGGA)

JL. RS. YOSOMIHARJO 16 KEC. BOBOTSARI PURBALINGGA

12

1500000001679

PUSKESMAS BOJONG (PURBALINGGA)

13

1500000001682

14

MA11222I

SETYOWATI INDRAYANI


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

19

1500000001694

PUSKESMAS KARANGJAMBU (PURBALINGGA)

JL.RAYA KARANGJAMBU PURBALINGGA RT 09 RW 3

20

1500000001703

PUSKESMAS KARANGMONCOL (PURBALINGGA)

JL.RY BOBOTSARI-REMBANG KM 11 DS PEPEDAN PURBALINGGA KEC KARANGMONCOL RT 1 RW 8

21

1500000001693

PUSKESMAS KARANGREJA (PURBALINGGA)

22

1500000001685

23

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7619971

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

7621793

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

JL JL RAYA KARANGREJA KM 2 PURBALINGGA

7609219

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

PUSKESMAS KARANGTENGAH (PURBALINGGA)

JL.RY KARANG TENGAH KEC KERTANEGARA PURBALINGGA RT 11 RW 3

6599857

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

1500000001699

PUSKESMAS KEJOBONG (PURBALINGGA)

JL.RAYA KEJOBONG PURBALINGGA KEC KEJOBONG RT 01 RW 01

082281219 3

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

24

1500000001692

PUSKESMAS KEMANGKON (PURBALINGGA)

JL. RAYA PANICAN - KEDUNG BENDA 002/001 KEC. KEMANGKON PURBALINGGA

53381

6591566

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

25

1500000001680

PUSKESMAS KUTASARI (PURBALINGGA)

JL. RAYA TOBONG - KUTASARI PURBALINGGA

53361

6599183

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

26

1500000001698

PUSKESMAS KUTAWIS (PURBALINGGA)

JL.RY BUKATEJA-KUTAWIS KM 5 PURBALINGGA RT 1 RW 5

53382

7639694

DR NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

27

1500000001702

PUSKESMAS MREBET (PURBALINGGA)

JL. RAYA MANGUNEGARA KM 08 MANGKUNEGARA KEC. MREBET PURBALINGGA

53352

758186

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

28

1500000001689

PUSKESMAS PADAMARA (PURBALINGGA)

JL. RAYA PADAMARA KM 6 KEC. PADAMARA PURBALINGGA

53372

6598588

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

29

1500000001701

PUSKESMAS PENGADEGAN (PURBALINGGA)

JL.RY PENGADEGAN PURBALINGGA KEC PENGADEGAN RT 11 RW 5

53393

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

30

1500000001677

PUSKESMAS PURBALINGGA

JL. AW SUMARMO 70 PURBALINGGA

53319

DR. NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I

53355

891862


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

31

1500000001704

PUSKESMAS REMBANG (PURBALINGGA)

JL.SUDIRMAN KM 5 LOSARI KEC REMBANG

53356

6590539

DR.NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

32

1500000001681

PUSKESMAS SERAYU LARANGAN (PURBALINGGA)

JL RY SERAYU-LARANGAN KEC MREBET KM 5 PURBALINGGA RT 01 RW 01

53352

7635303

DR NONOT MULYONO

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

33

1500000000604

RS EMANUEL

JL.A.YANI PURWAREJA KLAMPOK

479030

YAKKUM

PER/21/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

34

0900000000001

RS ORTHOPAEDI PURWOKERTO

JL SOEPARDJO ROESTAM 99 PWT

6844166

PER/35/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

35

1500000000628

RS SINAR KASIH

JL MARTADIREJA II PURWOKERTO

638370

PER/22/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

36

1400000000179

RS WIJAYAKUSUMA

JL PROF HR BUNYAMIN PURWOKERTO

633062

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

37

1500000000416

RSI BANJARNEGARA

JL. RAYA BAWANG KM 8 BANJARNEGARA

082138783 429

DR. H SETYOKO M

PER/17/03/2015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

38

1400000000187

RSI PURWOKERTO

JL H MASYHURI NO 39 PURWOKERTO

630019

YARSI PURWOKERTO

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

39

1400000000187

RSI PURWOKERTO

JL H MASYHURI NO 39 PURWOKERTO

630019

YARSI PURWOKERTO

PER/001/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2017

40

1500000000680

RSKB JATIWINANGUN

JL JATIWINANGUN NO 54 PURWOKERTO

638169

PT SANATIO

PER/19/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

41

1400000000282

RSU HARAPAN IBU PURBALINGGA

JL MAYJEND SUNGKONO NO 1 PURBALINGGA

892222

YYS BANI SOBARI

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

42

1400000000238

RSUD AJIBARANG

JL RAYA PANCASAN

6570004

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

YAKKUM


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

43

1500000000467

RSUD BANYUMAS

JL RUMAH SAKIT NO 1 BANYUMAS

796031

PER/07/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

44

1400000000399

RSUD DR R GOETENG TAROENADIBRATA

JL TENTARA PELAJAR NO 22

896645

PER/37/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

45

1500000001279

RSUD HJ ANNA LASMANAH BANJARNEGARA

JL JEND SUDIRMAN 42 BANJARNEGARA

591464

PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

46

1500000000118

RSUD PROF DR MARGONO SOEKARJO

JL DR GUMBREG NO 1 PURWOKERTO

632708

PER/11/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

47

1500000000350

RUMAH SAKIT NIRMALA PURBALINGGA

JL. LETNAN YUSUF PURBALINGGA

892844

PER/16/032015

RS.TRAUMA CENTRE

02/03/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

L10- KANTOR CABANG UNGARAN

NAMA PROVIDER

ALAMAT

1

1500000000867

GRIYA PELATIHAN APAC (GRIPAC)

JL SOEKARNO HATTA KM.32 DESA HARJOSARI BAWEN

2

1500000001918

KLINIK "COCA-COLA"

JL SOEKARNO HATTA KM.30 BAWEN

3

1400000000657

KLINIK APAC INTI CORPORA

JL SOEKARNO HATTA KM 32 HARJOSARI BAWEN

4

1400000000657

KLINIK APAC INTI CORPORA

JL SOEKARNO HATTA KM 32 HARJOSARI BAWEN

MA11222I

YAYASAN NIRMALA HUSADA

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PT APAC INTI CORPORA

PER/03/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

JULIUS ROBIYANTO

PER/14/082015

RS.TRAUMA CENTRE

24/08/2015

24/08/2016

522888

H AGUNG WAHONO SH.MHUM

PER/10/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

522888

H AGUNG WAHONO SH.MHUM

PER/06/012016

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

522914


SM0480



230 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1500000001574

KLINIK PRATAMA "MANUNGGAL"

JL ARGO BUSONO NO.1

322480

KOPERASI PT DAMATEX

PER/09/062015

RS.TRAUMA CENTRE

22/06/2015

31/12/2015

6

1500000001917

KLINIK PRATAMA KALIMASADHA

JALAN RAYA SALATIGA BOYOLALI KM.9 TENGARAN

9546050

DR CHOIRUL ANAM

PER/13/082015

RS.TRAUMA CENTRE

20/08/2015

20/08/2016

7

7-631760693

KLINIK TRI KARYA

JL TIRTOMOYO NO.96 BANDUNGAN KAB. SEMARANG

029871237 8

LILIS WIJAYANTI

PER/15/112015

RS.TRAUMA CENTRE

26/11/2015

19/11/2016

8

1400000000656

KLINIK UMUM 24 JAM UMI HABIBAH

JL SYECH BASARUDIN KEL.NGEMPON, BERGAS

526225

SITI MUSRIYATUN

PER/05/012016

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

9

1400000000656

KLINIK UMUM 24 JAM UMI HABIBAH

JL SYECH BASARUDIN KEL.NGEMPON, BERGAS

526225

SITI MUSRIYATUN

PER/11/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

10

1500000000341

PUSKESMAS BAWEN

JL PALAGAN NO. 60 KEC. BAWEN

591539

DINAS KESEHATAN KAB.SEMARANG

PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

11

1500000000340

PUSKESMAS BERGAS

JL SOEKARNO HATTA KEC.BERGAS

6525695

DINAS KESEHATAN KAB SEMARANG

PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

12

1500000000338

PUSKESMAS DUREN

JL KENDALISODO NO.19 KEC.BANDUNGAN

711355


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

13

1500000000325

PUSKESMAS GETASAN

JL RAYA SALATIGA KOPENG KM 10 KEC.GETASAN

2838099


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

14

1500000000337

PUSKESMAS JAMBU

JL. RAYA SEMARANG MAGELANG KM 4 KEC.JAMBU

593532


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

15

1500000000339

PUSKESMAS PRINGAPUS

JL.HONGOWICONO NO.5 KEC. PRINGAPUS

25721150

DNIAS KESEHATAN KAB.SEMARANG

PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

16

1500000000336

PUSKESMAS SUMOWONO

JL.PAHLAWAN NO.15 KEC SUMOWONO

40575050


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

MA11222I

50661


SM0480



231 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

17

1500000000343

PUSKESMAS SURUH

JL RAYA SURUH PLUMBON KEC SURUH

2882262


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

18

1500000000342

PUSKESMAS SUSUKAN

JL RAYA SUSUKAN NO.96 KEC SUSUKAN

615066


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

19

1500000000344

PUSKESMAS TENGARAN

JL RAYA SALATIGA SOLO KM 9 KEC. TENGARAN


PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

20

1400000000016

RS PURI ASIH

JL JEND.SUDIRMAN NO. 169

323209

DR MUFTI SIRADJ,SPOG

PER/04/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

21

1400000000016

RS PURI ASIH

JL JEND.SUDIRMAN NO. 169

323209

DR MUFTI SIRADJ,SPOG

PER/18/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1400000000019

RSUD AMBARAWA

JL KARTINI NO. 101 AMBARAWA

591020

PEMDA KAB SEMARANG

PER/02/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

23

1400000000019

RSUD AMBARAWA

JL KARTINI NO. 101 AMBARAWA

591020

PEMDA KAB SEMARANG

PER/16/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

7-1395288578

RSUD KOTA SALATIGA

JL OSAMALIKI NO. 19 SALATIGA

PEMKOT SALATIGA

PER/03/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

25

1400000000101

RSUD KOTA SALATIGA

JL OSAMALIKI NO. 19

324074

PEMDA KOTA SALATIGA

PER/17/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

01728

RSUD SALATIGA

JL OSAMALIKI NO 19 SALATIGA

324074

KOTA MAGELANG

PER/03/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

27

1400000000018

RSUD UNGARAN

JL DIPONEGORO NO. 125 UNGARAN

6921006

PEMDA KAB.SEMARANG

PER/15/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

28

1400000000018

RSUD UNGARAN

JL DIPONEGORO NO. 125 UNGARAN

6921006

PEMDA KAB.SEMARANG

PER/01/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

MA11222I

50721


SM0480



232 / 322 09-02-2016 18:49:59


NO

KODE PROVIDER

:

L11- KANTOR CABANG SEMARANG KALIGAWE

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001891

KLINIK 24 JAM DELIMA SEHAT

JL FATMAWATI NO 21A SEMARANG

50111

6734367

DR. DODI WITJAKSONO

PER / 27 / 072015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

2

1500000001891

KLINIK 24 JAM DELIMA SEHAT

JL FATMAWATI NO 21A SEMARANG

50111

6734367

DR. DODI WITJAKSONO

PER/15/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

3

1500000001494

KLINIK KAWAN SEJATI

DS KARANGSARI RT 01/04 KARANGTENGAH DEMAK

089671458 335

NINDYA ANGGI SINANTARA

PER / 19 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

4

1500000001494

KLINIK KAWAN SEJATI

DS KARANGSARI RT 01/04 KARANGTENGAH DEMAK

089671458 335

NINDYA ANGGI SINANTARA

PER/09/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

5

1500000000967

KLINIK PHC PEDURUNGAN SEMARANG

JL WOLTERMONGINSIDI NO 93, PEDURUNGAN, SEMARANG

6714465

DR. SWASTY, SP.,M.

PER / 12 / 052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

6

1500000000921

KLINIK PHC TANJUNG EMAS SEMARANG

JL. USMAN JANATIN NO 8 SEMARANG

3549735

DR. DIAH KARI ARTATI, M.KES

PER / 12 / 052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

7

1500000001534

KLINIK PRATAMA DWI PUSPITA KALIGAWE

JL. RAYA KALIGAWE KM 7 NO 9 TRIMULYO SEMARANG

082180099 759

HJ. ANISFA BAKAR

PER/12/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

8

1500000001534

KLINIK PRATAMA DWI PUSPITA KALIGAWE

JL. RAYA KALIGAWE KM 7 NO 9 TRIMULYO SEMARANG

082180099 759

HJ. ANISFA BAKAR

PER / 23 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

9

1500000001532

KLINIK PRATAMA DWI PUSPITA KARANGAWEN

JL. BRAMBANG NO 217 RT 05/02 BRAMBANG - DEMAK

082180099 759

HJ. ANISFA BAKAR

PER / 21 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

10

1500000001532

KLINIK PRATAMA DWI PUSPITA KARANGAWEN

JL. BRAMBANG NO 217 RT 05/02 BRAMBANG - DEMAK

082180099 759

HJ. ANISFA BAKAR

PER/10/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

11

1500000001533

KLINIK PRATAMA DWI PUSPITA PEDURUNGAN

JL. BRIG.JEND. SUDIARTO NO 512 SEMARANG

082180099 759

HJ. ANISFA BAKAR

PER / 22 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001533

KLINIK PRATAMA DWI PUSPITA PEDURUNGAN

JL. BRIG.JEND. SUDIARTO NO 512 SEMARANG

082180099 759

HJ. ANISFA BAKAR

PER/11/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

MA11222I


SM0480



233 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1400000000261

KLINIK PRATAMA NAYAKA ERA HUSADA 03

JL RAYA KALIGAWE KM5,5

70572297

PT NAYAKA ERA HUSADA SEMARANG

PER / 04 / 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

14

1400000000261

KLINIK PRATAMA NAYAKA ERA HUSADA 03

JL RAYA KALIGAWE KM5,5

70572297


PER/04/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

15

1500000001381


JL SEMARANG-DEMAK KM 15 WONOKERTO KARANGTENGAH DEMAK

7605621


PER / 16 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

16

1500000001381


JL SEMARANG-DEMAK KM 15 WONOKERTO KARANGTENGAH DEMAK

7605621


PER/08/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

17

1500000001380


JL SULTAN FATAH NO 47 DEMAK

7605621


PER / 17 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

18

1500000001380


JL SULTAN FATAH NO 47 DEMAK

7605621


PER/07/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

19

1500000001807

KLINIK PRATAMA RAWAT INAP KELUARGA SAKINAH

JL TELAGA KENCANA RAYA NO 15 BATURSARI MRANGGEN DEMAK

76580381

DR. AISYAH LAHDJI

PER/14/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

20

1500000001807

KLINIK PRATAMA RAWAT INAP KELUARGA SAKINAH

JL TELAGA KENCANA RAYA NO 15 BATURSARI MRANGGEN DEMAK

76580381

DR. AISYAH LAHDJI

PER / 24 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

21

1500000001539

KLINIK PRATAMA SAYUNG HUSADA DEMAK

JL. RAYA SAYUNG KM 10 SAYUNG - DEMAK

6591137

DR. FUAD ALHAMIDY

PER / 20 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

22

1500000001539

KLINIK PRATAMA SAYUNG HUSADA DEMAK

JL. RAYA SAYUNG KM 10 SAYUNG - DEMAK

6591137

DR. FUAD ALHAMIDY

PER/13/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

23

1500000001333

KLINIK PRATAMA SEHAT UTAMA

JL. MEDOHO RAYA NO 21 SAMBIREJO SEMARANG

6719222

HJ. SRI WAHYUNI MAHMUD, AM

PER / 18 / 062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

24

1500000001333

KLINIK PRATAMA SEHAT UTAMA

JL. MEDOHO RAYA NO 21 SAMBIREJO SEMARANG

6719222

HJ. SRI WAHYUNI MAHMUD, AM

PER/06/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

MA11222I


SM0480



234 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1500000001035

KLINIK PUCANG ANOM MEDIKA

JL PUCANG ANOM RAYA NO 30, MRANGGEN, DEMAK

76743362

DR. RIANA VITA

PER / 13 / 052015

RS.TRAUMA CENTRE

04/05/2015

03/05/2016

26

1300000000006

RS ISLAM NU DEMAK (RS TRAUMA CENTER JKK)

JL JOGOLOYO NO 09 DEMAK

685723

DR NUNUK SRI LESTARI

PER/02/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

27

1300000000006

RS ISLAM NU DEMAK (RS TRAUMA CENTER JKK)

JL JOGOLOYO NO 09 DEMAK

685723

DR NUNUK SRI LESTARI

PER / 03 / 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

28

1100000000006

RS ISLAM SULTAN AGUNG (RS TRAUMA CENTER JKK)

JL RAYA KALIGAWE KM 4 SEMARANG

6580019

DR MASYHUDI,MSI

PER/01/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2017

29

1100000000006

RS ISLAM SULTAN AGUNG (RS TRAUMA CENTER JKK)

JL RAYA KALIGAWE KM 4 SEMARANG

6580019

DR MASYHUDI,MSI

PER / 01 / 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

30

1300000000033

RS PANTI WILSA CITARUM SEMARANG (RSTC JKK)

JL CITARUM NO 98 SEMARANG

3546040

DR SUSETYO, SPA

PER / 02 / 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

31

1300000000033

RS PANTI WILSA CITARUM SEMARANG (RSTC JKK)

JL CITARUM NO 98 SEMARANG

3546040

DR SUSETYO, SPA

PER/03/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

32

1400000000402

RSUD SUNAN KALIJAGA (RSTC)

JL. SULTAN FATAH 669/50 DEMAK

685018

RSUD KAB. DEMAK

PER/05/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1500000000715

MA11222I

:

N00- KANTOR CABANG SURABAYA KARIMUNJAWA

NAMA PROVIDER

ANUGERAH KARYA MEDIKA CEMENGKALANG SIDOARJO

ALAMAT

RUKO PURI INDAH BLOK 30,JATICEMENGKALANG-SIDOARJO

KODE POS

IKS TELEPON

PIMPINAN NO IKS

031715542 59

SUSILO HENDROWARSITO

PER/09/012015



AWAL IKS 01/01/2016


SM0480



235 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1500000000715

ANUGERAH KARYA MEDIKA CEMENGKALANG SIDOARJO

RUKO PURI INDAH BLOK 30,JATICEMENGKALANG-SIDOARJO

031715542 59

SUSILO HENDROWARSITO

PER/15/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

3

1500000000717

ANUGERAH KARYA MEDIKA DEMAK

JL. DEMAK 375 SURABAYA

081130514 3

CV. ANUGERAH KARYA MEDIKA

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1500000000717

ANUGERAH KARYA MEDIKA DEMAK

JL. DEMAK 375 SURABAYA

081130514 3


PER/14/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

5

1500000000720

ANUGERAH KARYA MEDIKA GUNUNGSARI

JL. GUNUNGSARI NO.124 SURABAYA

5675589


PER/13/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

6

1500000000720

ANUGERAH KARYA MEDIKA GUNUNGSARI

JL. GUNUNGSARI NO.124 SURABAYA

5675589


PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7

1500000000712

BP 14

JL. PUCANG ANOM TIMUR NO. 35 SURABAYA

70701255

DR SURANADI SUGANDA

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

8

1500000000712

BP 14

JL. PUCANG ANOM TIMUR NO. 35 SURABAYA

70701255

DR SURANADI SUGANDA

PER/10/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1500000001466

BRAIN CLINIC

JL. SULAWESI NO.63 SURABAYA

5018800

PT. NEURO SENTRA HUSADA

PER/11/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1500000001466

BRAIN CLINIC

JL. SULAWESI NO.63 SURABAYA

5018800

PT. NEURO SENTRA HUSADA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

11

1500000001555

DIT POL AIR

JALAN INTAN NO.1 - TANJUNG PERAK.

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001030

KLINIK ABDI MULIA HR MUHAMMAD

JL HR MOHAMMAD KAV 401-403 SURABAYA

7319619

YAYASAN ABDI MULIA

PER/12/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000001030

KLINIK ABDI MULIA HR MUHAMMAD

JL HR MOHAMMAD KAV 401-403 SURABAYA

7319619

YAYASAN ABDI MULIA

PER/20/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


SM0480



236 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

14

1500000001031

KLINIK ABDI MULIA WISMA PERMAI

JL. WISMA PERMAI BARAT III/FP 12 SURABAYA

0315944122

YAYASAN ABDI MULIA

PER/12/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

1500000001031

KLINIK ABDI MULIA WISMA PERMAI

JL. WISMA PERMAI BARAT III/FP 12 SURABAYA

0315944122

YAYASAN ABDI MULIA

PER/21/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

16

1500000000719

KLINIK HEALTHY

JL NGAGEL TIRTO 25-27

5040990

KLINIK BEDAH & PRAKTEK DR HEALTHY

PER/13/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000000719

KLINIK HEALTHY

JL NGAGEL TIRTO 25-27

5040990

KLINIK BEDAH & PRAKTEK DR HEALTHY

PER/12/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

18

1500000001071

KLINIK KENCANA MEDIKA

JL. KENDANGSARI NO. 78 SURABAYA

8498880


PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

19

1500000001071


JL. KENDANGSARI NO. 78 SURABAYA

8498880


PER/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1500000000716

KLINIK MEDIS AMBENGAN

JL.AMBENGAN 35 SURABAYA

081832211 9

CV. KARYA PUTRA AMBENGAN

PER/16/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

21

1500000000716

KLINIK MEDIS AMBENGAN

JL.AMBENGAN 35 SURABAYA

081832211 9

CV. KARYA PUTRA AMBENGAN

PER/15/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

1500000001072

KLINIK MEDPOINT

JL. RAYA LONTAR 229 SURABAYA

7524067

KLINIK MEDPOINT

PER/16/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1500000001072

KLINIK MEDPOINT


7524067

KLINIK MEDPOINT

PER/23/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

24

1500000001072

KLINIK MEDPOINT


7524067

KLINIK MEDPOINT

PER/23/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

25

1500000001487

KLINIK MODERN DASA MEDIKA

JL. DIPONEGORO NO 161-163 SURABAYA

5677088

PT.PERKEBUNAN NUSANTARA X (PERSERO)

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


SM0480



237 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

26

1500000001487

KLINIK MODERN DASA MEDIKA

JL. DIPONEGORO NO 161-163 SURABAYA

5677088

PT.PERKEBUNAN NUSANTARA X (PERSERO)

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

27

1400000000445


JL RAYA KRIKILAN NO 259 DRIYOREJO GRESIK

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

1400000000445


JL RAYA KRIKILAN NO 259 DRIYOREJO GRESIK

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

29

1400000000450


JL RA KARTINI NO 236 C-9 KEBOMAS GRESIK

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

30

1400000000450


JL RA KARTINI NO 236 C-9 KEBOMAS GRESIK

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

31

1400000000449


RUKO SEPANJANG TOWN HOUSE C1-C3 JL KALIJATEN

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

32

1400000000449


RUKO SEPANJANG TOWN HOUSE C1-C3 JL KALIJATEN

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

1500000000713

KLINIK PRATAMA 65

JL. GUBENG KERTAJAYA X1/38 SURABAYA

088835356 66

DR ADRIANUS MICHAEL FOEH

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

34

1500000000713

KLINIK PRATAMA 65

JL. GUBENG KERTAJAYA X1/38 SURABAYA

088835356 66

DR ADRIANUS MICHAEL FOEH

PER/18/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

35

1500000000718

KLINIK PRATAMA ALAMANDA

JL. DINOYO NO.20-II

5677767

CV. INTI PRATAMA

PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

36

1500000000718


JL. DINOYO NO.20-II

5677767

CV. INTI PRATAMA

PER/19/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

37

1500000000718


JL. DINOYO NO.20-II

5677767

CV. INTI PRATAMA

PER/11/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

38

1400000000443

KLINIK PRATAMA NAYAKA 02

JL MASTRIP NO 150 KEBRAON SURABAYA

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

39

1400000000443

KLINIK PRATAMA NAYAKA 02

JL MASTRIP NO 150 KEBRAON SURABAYA

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

40

1400000000439


JL CENDRAWASIH NO 28B

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

41

1400000000439


JL CENDRAWASIH NO 28B

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

42

1400000000446


JL ASEM ROWO KALI NO 1

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

43

1400000000446


JL ASEM ROWO KALI NO 1

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

44

1400000000447


JL PANDEGILING NO 117A

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

45

1400000000447


JL PANDEGILING NO 117A

7887273


PER/17/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

46

1400000000448


JL TANDES ASRI NO 64

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

47

1400000000448


JL TANDES ASRI NO 64

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

48

1400000000451


JL KALI RUNGKUT NO 52

7887273


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

49

1400000000451


JL KALI RUNGKUT NO 52

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

50

1500000001483

KLINIK PRATAMA PG KREMBOONG

DESA KREMBOONG SIDOARJO

081332074 648

PTPN X

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

51

1500000001483



081332074 648

PTPN X

PER/24/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

52

1500000001483



081332074 648

PTPN X

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

53

1500000001484

KLINIK PRATAMA PG TOELANGAN

DESA TULANGAN SIDOARJO

PTPN X

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

54

1500000001484



PTPN X

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

55

1500000001484



PTPN X

PER/24/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

56

1500000001485

KLINIK PRATAMA PG WATOETOELIS

DESA TEMU KECAMATAN PRAMBON SIDOARJO

081332074 648

PTPN X

PER/24/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

57

1500000001485



081332074 648

PTPN X

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

58

1500000001485



081332074 648

PTPN X

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

59

1500000001486

KLINIK ST.VINCENTIUS A PAULO (KARAH)

JL. KARAH NO.200 SURABAYA

5677562

YAYASAN ARNOLDUS

PER/20/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

60

1500000001486

KLINIK ST.VINCENTIUS A PAULO (KARAH)

JL. KARAH NO.200 SURABAYA

5677562

YAYASAN ARNOLDUS

PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

61

1500000001029

KLINIK UTAMA KASIH KARUNIA

JL. RAYA SATELIT BARAT AS NO.1 SURABAYA

7327688

YAYASAN KASIH KARUNIA

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

62

1500000001029

KLINIK UTAMA KASIH KARUNIA

JL. RAYA SATELIT BARAT AS NO.1 SURABAYA

63

1500000001558

POLIKLINIK BIDDOKKES A. YANI (SATKES MERTOJOSO)

64

1500000001556

65

KODE POS

IKS TELEPON

PIMPINAN NO IKS

AWAL IKS

AKHIR IKS

PER/21/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL. A. YANI NO. 116 SURABAYA

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

POLRES PELABUHAN TANJUNG PERAK

JALAN KALIANGET NO. 1, SURABAYA, JAWA TIMUR 60165

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

1500000001559

POLRESTABES SURABAYA

JL. SIKATAN 1, SURABAYA

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

66

1500000000478

RS BHAKTI DHARMA HUSADA

JL RAYA KENDUNG NO 115-117

7404444

PEMERINTAH KOTA SURABAYA

PER/06/01/2015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

67

1500000000478

RS BHAKTI DHARMA HUSADA

JL RAYA KENDUNG NO 115-117

7404444

PEMERINTAH KOTA SURABAYA

PER/07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

68

0700000000013

RS BHAYANGKARA HS SAMSOERI M

JL. A YANI NO. 116 SURABAYA

8292227

POLDA JATIM

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

69

0700000000013

RS BHAYANGKARA HS SAMSOERI M

JL. A YANI NO. 116 SURABAYA

8292227

POLDA JATIM

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

70

1500000000714

RS MARINIR EWA PANGALILA GUNUNGSARI

JL GOLF I NO 1A SURABAYA

0315663539

TNI ANGKATAN LAUT

PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

71

1500000000714

RS MARINIR EWA PANGALILA GUNUNGSARI

JL GOLF I NO 1A SURABAYA

0315663539

TNI ANGKATAN LAUT

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

72

1500000001385

RS MATA UNDAAN

JL UNDAAN KULON 17-19 SURABAYA

5343806

RS MATA UNDAAN

PER/22/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

73

1500000001385

RS MATA UNDAAN

JL UNDAAN KULON 17-19 SURABAYA

5343806

RS MATA UNDAAN

PER/24/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I

7327688

YAYASAN KASIH KARUNIA

TIPE IKS


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

74

1500000000549

RS TINGKAT III BRAWIJAYA

JL KESATRIAN NO 17

5611272

KODAM V BRAWIJAYA

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

75

1500000000549

RS TINGKAT III BRAWIJAYA

JL KESATRIAN NO 17

5611272

KODAM V BRAWIJAYA

PER/07/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

76

1500000000187

RS TNI AU SOEMITRO SURABAYA

JL. SERAYU NO 17 SURABAYA

5662593

TNI AU

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

77

1500000000187

RS TNI AU SOEMITRO SURABAYA

JL. SERAYU NO 17 SURABAYA

5662593

TNI AU

PER/05/022015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

78

1500000001384

RS UNIVERSITAS AIRLANGGA

KAMPUS C MULYOREJO UNIVERSITAS AIRLANGGA SBY

8439473

UNIVERSITAS AIRLANGGA

PER/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

79

1500000001384

RS UNIVERSITAS AIRLANGGA

KAMPUS C MULYOREJO UNIVERSITAS AIRLANGGA SBY

8439473

UNIVERSITAS AIRLANGGA

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

80

1500000000711

RS.DKT GUBENG POJOKBANTUAN 05.08.05 SURABAYA

JL. GUBENG POJOK NO.21

5310069

DRG.OUTI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

81

1500000000711

RS.DKT GUBENG POJOKBANTUAN 05.08.05 SURABAYA

JL. GUBENG POJOK NO.21

5310069

DRG.OUTI

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

82

1400000000360

RUMAH SAKIT SURABAYA MEDICAL SERVICE

JL. KAPUAS NO.2 SURABAYA

5686161

YAYASAN PUJA HUSADA

PER/23/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

83

1400000000360

RUMAH SAKIT SURABAYA MEDICAL SERVICE

JL. KAPUAS NO.2 SURABAYA

5686161

YAYASAN PUJA HUSADA

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

84

1500000001557

SAT BRIMOB

JL. GRESIK 39 SURABAYA

PER/06/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

85

1500000001201

UPT PELATIHAN KERJA SURABAYA

JL.DUKUH MENANGGAL III/29 SURABAYA

PER/18/052015

RS.TRAUMA CENTRE

19/05/2015

19/05/2016

MA11222I

8290071

DRS. WIDJIL SAPTADI


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NO

KODE PROVIDER

:

N01- KANTOR CABANG KEDIRI

NAMA PROVIDER

ALAMAT

1

1500000000732

BP SWASTA DAN BKIA SWASTA MITRA HUSADA

JLN. BROMO V NO.3 RT01 RW01 DS TUNJUNGREJO KEC.LOCERET KABUPATEN NGANJUK

2

1400000000662

KLINIK ASFIYAK GRAHA MEDIKA

JL. KANDANGAN NO.63A DS KENCONG TENGAH KEC KEPUNG KABUPATEN KEDIRI

3

1500000000731

KLINIK PRATAMA RAWAT JALAN MITRA 02

4

1500000000730

5

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

IR. H. TEUKU ISMAIL

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

PT. ASFIYAK GRAHA MEDIKA

PER/22/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

JL. IMAM BONJOL NO.2 DESA PELEM KEC.KERTOSONO KABUPATEN NGANJUK

IR. H. TEUKU ISMAIL

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

KLINIK PRATAMA RAWAT JALAN MITRA HUSADA I

JLN. YOS SUDARSO NO.37 DS. TULUNGREJO KEC.PARE KABUPATEN KEDIRI

KLINIK PRATAMA RAWAT JALAN MITRA HUSADA I

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

1500000000933

KLINIK SURYA PRIMA HUSADA

JL. RAYA KUNJANG RT1 RW2 KUNJANG KABUPATEN KEDIRI

KLINIK SURYA PRIMA HUSADA

PER/12/052015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

6

1500000001620

POLIKLINIK POLRES KEDIRI

JL. PB SUDIRMAN NO. 56 PARE

POLIKLINIK POLRES KEDIRI

PER/18/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

7

1500000001619

POLIKLINIK POLRES KOTA KEDIRI

JLN. BRAWIJAYA NO. 25 KEDIRI

POLIKLINIK POLRES KOTA KEDIRI

PER/17/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

8

1500000001622

POLIKLINIK POLRES NGANJUK

JALAN GATOT SUBROTO NO. 116, NGANJUK

POLIKLINIK POLRES NGANJUK

PER/19/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

9

1000000000008

RS BHAYANGKARA KEDIRI

JL.KOMBES POL. DURYAT NO. 17 KEDIRI

POLRI

PER/33/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1000000000008



POLRI

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1000000000008



POLRI

PER/18/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

12

07189

RS BHAYANGKARA NGANJUK

JL. ABDUL RAHMAN SALEH NO. 52-56

PER/23/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

395066

7660694

3218896


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

POLRI

PER/5113/12201 5

RS.TRAUMA CENTRE

28/12/2015

31/12/2016

671939

RSU AURA SYIFA

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

JL. JOYOBOYO NO. 42 DLOPO KEC. NGASEM KABUPATEN KEDIRI

671939

RSU AURA SYIFA

PER/31/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

RSU MUHAMMADIYAH SURYA MELATI

JL. RAYA NGADILUWIH WATES KM 10 DS. NGLETIH KANDAT

441748

RSU MUHAMMADIYAH SURYA MELATI

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

0800000000031

RSUD GAMBIRAN

JL.K.H.WAHID HASYIM NO 64

773097

DR.ENDANG WAHYU L,MARS

PER/19/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

18

0800000000031

RSUD GAMBIRAN

JL.K.H.WAHID HASYIM NO 64

773097

DR.ENDANG WAHYU L,MARS

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

19

1500000001542

RSUD KABUPATEN KEDIRI

JLN. PAHLAWAN KUSUMA BANGSA NO. 1 PARE KEDIRI

391718


PER/16/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

20

1500000001542


JLN. PAHLAWAN KUSUMA BANGSA NO. 1 PARE KEDIRI

391718


PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1400000000564

RSUD KERTOSONO

JL. SUPRIYADI NO. 29 KERTOSONO

551118

RUMAH SAKIT UMUM DAERAH KERTOSONO

PER/17/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1400000000564

RSUD KERTOSONO

JL. SUPRIYADI NO. 29 KERTOSONO

551118

RUMAH SAKIT UMUM DAERAH KERTOSONO

PER/25/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1500000000863

RUMAH SAKIT BEDAH ARGA HUSADA

DS BRANGGAHAN KEC NGADILUWIH KABUPATEN KEDIRI

476376

YAYASAN ARGA HUSADA UTAMA

PER/28/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1500000000863

RUMAH SAKIT BEDAH ARGA HUSADA

DS BRANGGAHAN KEC NGADILUWIH KABUPATEN KEDIRI

476376

YAYASAN ARGA HUSADA UTAMA

PER/11/052015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

13

04783

RS. BHAYANGKARA KEDIRI

JL. KOMBES POL.DURYAT NO.17 KEDIRI

14

1500000000725

RSU AURA SYIFA

JL. JOYOBOYO NO. 42 DLOPO KEC. NGASEM KABUPATEN KEDIRI

15

1500000000725

RSU AURA SYIFA

16

1500000001258

17

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1400000000421

RUMAH SAKIT BHAYANGKARA NGANJUK

JL. ABDUL RAHMAN SALEH NO. 56 NGANJUK 64415

3218896

KEPOLISIAN REPUBLIK INDONESIA

PER/21/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

1500000000940

RUMAH SAKIT HVA TOELOENGREDJO

JL. A YANI NO. 25 PARE KABUPATEN KEDIRI

391047

RS PTP XXI TOELOENGREDJO

PER/13/052015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

27

1500000000940

RUMAH SAKIT HVA TOELOENGREDJO

JL. A YANI NO. 25 PARE KABUPATEN KEDIRI

391047

RS PTP XXI TOELOENGREDJO

PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

1400000000206

RUMAH SAKIT MUHAMMADIYAH AHMAD DAHLAN

JL. GATOT SUBROTO 84 KOTA KEDIRI

773115

MKKM PD MUHAMMADIYAH KOTA KEDIRI

PER/20/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

29

1400000000206

RUMAH SAKIT MUHAMMADIYAH AHMAD DAHLAN

JL. GATOT SUBROTO 84 KOTA KEDIRI

773115

MKKM PD MUHAMMADIYAH KOTA KEDIRI

PER/27/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

30

1500000000723

RUMAH SAKIT MUHAMMADIYAH SITI KHODIJAH

JL. DR.SUTOMO NO.322 SUKOREJO KEC.GURAH KABUPATEN KEDIRI

545481


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

31

1500000000723


JL. DR.SUTOMO NO.322 SUKOREJO KEC.GURAH KABUPATEN KEDIRI

545481


PER/32/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

32

1500000001259

RUMAH SAKIT UMUM LIRBOYO

JL. DR. SAHARDJO CAMPUREJO

778165

YAYASAN PONPES HIDAYATUL MUBTADIEN

PER/15/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

33

1500000001637

RUMKIT TK IV (DKT) TNI AD KEDIRI

JL. MAYJEN SUNGKONO NO. 44 KEDIRI

687801

RUMKIT TK IV (DKT) TNI AD KEDIRI

PER/20/062015

RS.TRAUMA CENTRE

01/07/2015

31/12/2015

1500000000659

UNIT PELAKSANA TEKNIS PELATIHAN KERJA KEDIRI

DS. GEDANGSEWU KEC. PARE KABUPATEN KEDIRI

391583

PEMERINTAH PROVINSI JAWA TIMUR DINAS TENAGA KERJA TRANSMIGRASI DAN KEPENDUDUKAN

PER/03/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

34

KANTOR CABANG

MA11222I

:

N02- KANTOR CABANG MALANG


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000919

KLINIK NAYAKA ERA HUSADA 02

JL. RAYA PAKIS KEMBAR NO. 174 A PAKIS

796858

PT.NAYAKA ERA HUSADA

PER/158I/052015

RS.TRAUMA CENTRE

19/05/2015

18/05/2016

2

1500000000916


JL. A. YANI NO. 20 F BLIMBING

496261

PT.NAYAKA ERA HUSADA

PER/158/052015

RS.TRAUMA CENTRE

19/05/2015

18/05/2016

3

1500000001672

KLINIK POLRES BARU

JLN. HASANUDDIN NO.1 JUNREJO

PER/177/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

4

1500000001673

KLINIK POLRES MALANG

JL PAHLAWAN TRIP NO 1

65111

551356

DR AKHMAD PRABOWO

PER/178/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

5

1500000001676

KLINIK RAWAT JALAN MUTIARA SEHAT

PERUM PTP 23 BLOK I 27 RT 01 RW 04 DS BANJARARUM SINGOSARI

65153

4949699

LOVI KRISADI ENDARI

PER/180/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

6

1300000000016

RS. BAPTIS BATU

JL. RAYA TLEKUNG NO.1 JUNREJO

594161

YAYASAN BAPTIS INDONESIA

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

7

1300000000016

RS. BAPTIS BATU

JL. RAYA TLEKUNG NO.1 JUNREJO

594161

YAYASAN BAPTIS INDONESIA

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1200000000012

RS. BHAYANGKARA HASTA BRATA

JL. RA KARTINI NO. 01

597023

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1200000000012

RS. BHAYANGKARA HASTA BRATA

JL. RA KARTINI NO. 01

597023

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

10

1200000000008

RS. WAVA HUSADA

JL. PANGLIMA SUDIRMAN NO. 99 A DILEM KEPANJEN

393000

ABNASAMANHUDI SAUTIKA HUSADA PT

PER/11/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1200000000008

RS. WAVA HUSADA

JL. PANGLIMA SUDIRMAN NO. 99 A DILEM KEPANJEN

393000

ABNASAMANHUDI SAUTIKA HUSADA PT

PER/11/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

12

1500000000046

RSI GONDANGLEGI

JL HAYAM WURUK NO 66 GONDANGLEGI

879047

YAYASAN RS GONDANGLEGI

PER/04/01/01201 6

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000046

RSI GONDANGLEGI

JL HAYAM WURUK NO 66 GONDANGLEGI

879047

YAYASAN RS GONDANGLEGI

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

14

1400000000002

RSU ISLAM MADINAH

JL. RAYA SUKOSARI 32 KASEMBON

326688

YAY AL MADINAH

PER/12/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

15

1400000000002

RSU ISLAM MADINAH

JL. RAYA SUKOSARI 32 KASEMBON

326688

YAY AL MADINAH

PER/12/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

1200000000009

RSU. LAWANG MEDIKA

JL. DR. CIPTO NO. 08 BEDALI LAWANG

426705

PT. DASA USAHA JAYA

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1200000000009

RSU. LAWANG MEDIKA

JL. DR. CIPTO NO. 08 BEDALI LAWANG

426705

PT. DASA USAHA JAYA

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

18

1200000000010

RSU. PRASETYA HUSADA

JL. RAYA NGIJO NO. 25 KARANG PLOSO

460558

SUJIATI, SST,MM.KES

PER/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

19

1200000000010

RSU. PRASETYA HUSADA

JL. RAYA NGIJO NO. 25 KARANG PLOSO

460558

SUJIATI, SST,MM.KES

PER/08/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

20

7-375291327

RSUD LAWANG

JL RA KARTINI 5 LAWANG

PEMERINTAH

PER/183/092015

RS.TRAUMA CENTRE

02/12/2015

31/08/2016

21

1500000000920

RUMAH SAKIT BALA KESELAMATAN BOKOR

JL. JEND. A. YANI NO. 91 TUREN

824002

YAYASAN PELAYANAN KESEHATAN BALA KESELAMATAN

PER/159/052015

RS.TRAUMA CENTRE

20/05/2015

19/05/2016

22

7-938470983

RUMAH SAKIT DR. ETTY ASHARTO

JLN. SAJID NO.44 BATU

65313

341591054

DR.RACHMAD ARI IRMAWAN

PER/184/092015

RS.TRAUMA CENTRE

31/12/2015

31/08/2016

23

1500000001674

RUMAH SAKIT ISLAM MALANG

JL MT HARYONO 139

65144

551356

DR H TRIWAHYU SARWIYATA

PER/179/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

24

1000000000011

RUMAH SAKIT MARSUDI WALUYO

JL.RAYA MONDOROKO KM 9 SINGOSARI MALANG

458919

DR.KRISTIWI HANGGRIYANI

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

65213


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1000000000011



458919


PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1000000000011



458919


PER/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

27

1000000000013

RUMAH SAKIT PANTI NIRMALA

JL.KEBALEN WETAN NO.8

331100

DRG.BENNY ANDOKO WIBISONO

PER/07/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

28

1000000000013

RUMAH SAKIT PANTI NIRMALA

JL.KEBALEN WETAN NO.8

331100

DRG.BENNY ANDOKO WIBISONO

PER/ 07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

29

1000000000012

RUMAH SAKIT PRIMA HUSADA

JL.BANJARARUM SELATAN NO 3 MONDOROKO-SINGOSARI MALANG

458679

DR.SADI HARIONO

PER/09/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

30

1000000000012

RUMAH SAKIT PRIMA HUSADA

JL.BANJARARUM SELATAN NO 3 MONDOROKO-SINGOSARI MALANG

458679

DR.SADI HARIONO

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

31

1200000000011

RUMAH SAKIT UMUM BEN MARI

JL. RAYA KENDAL PAYAK NO 17 PAKISAJI

837777

PT. RS BEN MARI

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

32

1200000000011

RUMAH SAKIT UMUM BEN MARI

JL. RAYA KENDAL PAYAK NO 17 PAKISAJI

837777

PT. RS BEN MARI

PER/02/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

1400000000001

RUMAH SAKIT UMUM DAERAH DR. SAIFUL ANWAR

JL. JAKSA AGUNG SUPRAPTO

362101

PEMPROV JATIM

PER/10/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

34

1400000000001



362101

PEMPROV JATIM

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

35

1400000000001



362101

PEMPROV JATIM

PER/10/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

36

7-1238038834

RUMAH SAKIT UMUM KARSA HUSADA BATU

JLN. A . YANI 10-13

341591036

PROVINSI

PER/13/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

65311


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

37

1500000001316

UPT PELATHAN KERJA SINGOSARI

JL. RAYA SINGOSARI

458055


PER/157/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

38

1500000001316


JL. RAYA SINGOSARI

458055


PER/15/012016

RS.TRAUMA CENTRE

04/02/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

N03- KANTOR CABANG JEMBER

NAMA PROVIDER

ALAMAT

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

POLDA JATIM

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

338044

POLDA JATIM

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

889022

POLDA JATIM

PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

PT ROLAS NUSANTARA MEDIKA JEMBER

PER/06/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

082336624 828

DR EKA WARDHANI

PER/22/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL KYAI ILYAS NO 07 TOMPOKERSAN LUMAJANG

88646

POLDA JATIM

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JL JAYA NEGARA 7 JEMBER

422701

YAYASAN BINA SEHAT

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1

1500000001593

FKTP POLRES BONDOWOSO

JL JEND A YANI 29

2

1500000001592

FKTP POLRES JEMBER

JL RA KARTINI 17

3

1500000001590

FKTP POLRES LUMAJANG

JL ALUN ALUN UTARA 11

4

1500000000652

KLINIK ROLAS MEDIKA

JL GAJAH MADA NO 15

5

1400000000625

RS BHAYANGKARA BONDOWOSO

JL JEND POL SUCIPTO JUDODIHARJO NO 12 BONDOWOSO

6

1500000001561

RS BHAYANGKARA TK III LUMAJANG

7

1500000001591

RS BINA SEHAT

MA11222I

KODE POS


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

7-1672273183

RS CITRA HUSADA

JL. TERATAI NO. 22 DS. GEBANG KEC. PATRANG KOTA JEMBER

68117

033148620 0

YAYASAN CITRA HUSADA

PER/004/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

9

7-1672273183

RS CITRA HUSADA

JL. TERATAI NO. 22 DS. GEBANG KEC. PATRANG KOTA JEMBER

68117

033148620 0

YAYASAN CITRA HUSADA

PER/4/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

10

1400000000626

RS ISLAM LUMAJANG

JL KYAI MUKSIN 19 LUMAJANG

887999

DR R ELYUNAR DWI NUGROHO

PER/20/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

7-1692033973

RS JEMBER KLINIK

JALAN BEDADUNG NO.2 JEMBER LOR PATRANG JEMBER

033148710 4

PT NUSANTARA MEDIKA UTAMA

PER/05/012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

12

1500000000647

RSD DR SOEBANDI

JL DR SOEBANDI NO 124

487441

PER/05/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

13

1500000000647

RSD DR SOEBANDI

JL DR SOEBANDI NO 124

487441

PER/05/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

14

1400000000009

RSU KALIWATES JEMBER

JL DIAH PITALOKA NO 4 A JEMBER

485967

PT ROLAS NUSANTARA MEDIKA

PER/21/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

1400000000009



485967


PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

16

1400000000009



485967


PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

17

7-777708533

RSUD DR H KOESNADI BONDOWOSO

JLPIERE TENDEAN BONDOWOSO

00000

DR AGUS SUWARDJITO, M KES

PER/16/102015

RS.TRAUMA CENTRE

02/12/2015

30/09/2016

18

7-1938064553

RSUD DR HARYOTO KAB LUMAJANG

JL BASUKI RAHMAD NO 5 LUMAJANG

67311

PEMPROV

PER/007/022016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

19

1500000000957

RUMAH SAKIT DAERAH BALUNG

JL RAMBIPUJI 19 BALUNG

PEMDA

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I

68111

033488166 6


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Periode : 01012015 s/d 31122016

NO

20

KODE PROVIDER

RUMAH SAKIT DAERAH KALISAT

1500000000956

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

:

ALAMAT

KODE POS

JL MH THAMRIN 31 KALISAT JEMBER

IKS TELEPON

PIMPINAN NO IKS

233388695

PEMDA

PER/07/052015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/05/2015


N04- KANTOR CABANG PASURUAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001062

BP JAMSOSTEK 22

JL. PUCANGSARI, SENGONAGUNG, PURWOSARI

7764043

CV CITRA MEDIKA

IKS/25/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

2

1500000001062

BP JAMSOSTEK 22

JL. PUCANGSARI, SENGONAGUNG, PURWOSARI

7764043

CV CITRA MEDIKA

IKS/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1500000001061

BP JAMSOSTEK 51

JL. TONGKOL NO. 2C, BANGIL

747731

CV CITRA MEDIKA

IKS/25/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

4

1500000001061

BP JAMSOSTEK 51

JL. TONGKOL NO. 2C, BANGIL

747731

CV CITRA MEDIKA

IKS/10/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

1500000001651

FKTP POLRES KAB PASURUAN

JL. DR.SUTOMO NO.1, BANGIL

POLRI

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2017

6

1500000001649

FKTP POLRES KOTA PASURUAN

JL. BALAI KOTA NO.3

POLRI

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2017

7

1500000001644

FKTP POLRES KOTA PROBOLINGGO

JL. ANGGREK NO.2

POLRI

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2017

8

1500000001647

FKTP POLRES PROBOLINGGO

JL. DR. M.SALEH NO.24

POLRI

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2017

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

9

1500000001336

KLINIK CITRA 10

JL. RAYA JAPANAN, GG.BANDENG PRESATO NO.2, GEMPOL

854335

CV CITRA MEDIKA

IKS/25/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

10

1500000001336

KLINIK CITRA 10

JL. RAYA JAPANAN, GG.BANDENG PRESATO NO.2, GEMPOL

854335

CV CITRA MEDIKA

IKS/11/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001340

KLINIK CITRA 2

JL. RAYA DRINGU GG.MARGOMULYO NO.2

843346

CV CITRA MEDIKA

IKS/25/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

12

1500000001340

KLINIK CITRA 2

JL. RAYA DRINGU GG.MARGOMULYO NO.2

843346

CV CITRA MEDIKA

IKS/15/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000001339

KLINIK CITRA 6

JL. MASTRIP GG.KELAPA GADING NO. 43

4430181

CV CITRA MEDIKA

IKS/25/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

14

1500000001339

KLINIK CITRA 6

JL. MASTRIP GG.KELAPA GADING NO. 43

4430181

CV CITRA MEDIKA

IKS/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

1500000001338

KLINIK CITRA PURWOSARI

JL. RAYA PURWOSARI NO. 21,

612244

CV CITRA MEDIKA

IKS/25/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

16

1500000001338

KLINIK CITRA PURWOSARI

JL. RAYA PURWOSARI NO. 21,

612244

CV CITRA MEDIKA

IKS/13/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000001337

KLINIK JAMSOSTEK CITRA 1

JL. RAYA NGOPAK NO. 8, REJOSO

482366

CV CITRA MEDIKA

IKS/12/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

18

1500000001337

KLINIK JAMSOSTEK CITRA 1

JL. RAYA NGOPAK NO. 8, REJOSO

482366

CV CITRA MEDIKA

IKS/25/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

19

1500000001045

KLINIK MITRA 125

GG LONDO NO. 22A, JAGIL, GAMBIRAN, PRIGEN

881459

CV MITRA HUSADA

IKS/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1500000001045

KLINIK MITRA 125

GG LONDO NO. 22A, JAGIL, GAMBIRAN, PRIGEN

881459

CV MITRA HUSADA

IKS/23/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

21

1500000001040

KLINIK MITRA 82

RUKO PERUM ISTANA BESTARI, JL. DR. WAHIDIN SUDIROHUSODO KEL. TAMANAN, KEC. BUGUL KIDUL,

6640508

CV. MITRA HUSADA

IKS/23/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

22

1500000001040

KLINIK MITRA 82

RUKO PERUM ISTANA BESTARI, JL. DR. WAHIDIN SUDIROHUSODO KEL. TAMANAN, KEC. BUGUL KIDUL,

6640508

CV. MITRA HUSADA

IKS/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1500000001044

KLINIK MITRA 91

JL. RAYA GONDANG LEGI NO. 04, BEJI

655291

CV MITRA HUSADA

IKS/07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1500000001044

KLINIK MITRA 91

JL. RAYA GONDANG LEGI NO. 04, BEJI

655291

CV MITRA HUSADA

IKS/23/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

25

1500000001043

KLINIK MITRA 95

JL. STADION 28 PANDAAN / JL. PATTIMURA

636028

CV MITRA HUSADA

IKS/23/05/2015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

26

1500000001043

KLINIK MITRA 95

JL. STADION 28 PANDAAN / JL. PATTIMURA

636028

CV MITRA HUSADA

IKS/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

27

1500000001052

KLINIK RAWAT INAP ISLAM AISYIYAH

JL. PAHLAWAN SUNARYO 257, KUTOREJO, PANDAAN

637367

IKS/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

1500000001052

KLINIK RAWAT INAP ISLAM AISYIYAH

JL. PAHLAWAN SUNARYO 257, KUTOREJO, PANDAAN

637367

IKS/24/052015

RS.TRAUMA CENTRE

25/05/2015

31/12/2015

29

1500000000768

RS BHAYANGKARA PUSDIK BRIMOB WATUKOSEK

JL. RAYA WATUKOSEK, GEMPOL

336050343

BRIMOB

PER/22/042015

RS.TRAUMA CENTRE

28/04/2015

28/04/2017

30

1500000001233

RS RIZANI HUSADA

JL. RAYA KOTAANYAR NO. 42

773444

PT RIZANI HUSADA

IKS/16/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

31

1500000001233

RS RIZANI HUSADA

JL. RAYA KOTAANYAR NO. 42

773444

PT RIZANI HUSADA

IKS/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

32

1400000000264

RSI MASYITHOH

JL. A. YANI NO. 6-7, BANGIL

741018

YAYASAN

PER/27/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

MA11222I


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253 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

33

1400000000264

RSI MASYITHOH

JL. A. YANI NO. 6-7, BANGIL

741018

YAYASAN

IKS/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

34

1400000000605

RSUD BANGIL

JL. RAYA RACI BANGIL

744900

DR. AGUNG BASUKI

IKS/29/122015

RS.TRAUMA CENTRE

21/12/2015

31/12/2016

35

1400000000432

RSUD DR MOHAMAD SALEH

JL MAYJEND PANJAITAN 65

433119

DR BAMBANG AGUS SUWIGNYA

IKS/28/112015

RS.TRAUMA CENTRE

21/12/2015

31/12/2016

36

1500000000514

RSUD DR. R. SOEDARSONO

JL . DR. WAHIDIN SUDIRO HUSODO NO. 1-4

421073

DR. SUDARMANTO

PER/19/042015

RS.TRAUMA CENTRE

01/04/2015

31/12/2015

37

1500000000087

RSUD TONGAS

JL RAYA TONGAS 229

511836

DRG KAMALIYAH TJIPLUK P.L, MMKES

IKS/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

1500000000087

RSUD TONGAS

JL RAYA TONGAS 229

511836

DRG KAMALIYAH TJIPLUK P.L, MMKES

PER/01/012015

RS.TRAUMA CENTRE

13/01/2015

31/12/2015

39

1400000000604

RSUD WALUYO JATI

JL. DR SOETOMO NO 1 KRAKSAAN

846877

DR ANANG BUDI Y.M.MKES

IKS/30/122015

RS.TRAUMA CENTRE

21/12/2015

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

N05- KANTOR CABANG MOJOKERTO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001601

BP JAMSOSTEK 106

JL RAYA WONOSARI NO 112 NGORO

61385

6817998

IR H TEUKU ISMAIL

PER/48/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1500000001601

BP JAMSOSTEK 106

JL RAYA WONOSARI NO 112 NGORO

61385

6817998

IR H TEUKU ISMAIL

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


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254 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

1500000000346

KLINIK ASY-SYIFA

JL RAYA PLOSO DS REJOAGUNG KEC PLOSO

61453

885995

DR ELDYANTO YUYUN

PER/09/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

4

1500000000346

KLINIK ASY-SYIFA

JL RAYA PLOSO DS REJOAGUNG KEC PLOSO

61453

885995

DR ELDYANTO YUYUN

PER/55/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

1500000001603

KLINIK CITA MULIA

PERUM WIKARSA BLOK G NO1 KENANTEN PURI

61311

323302

CV GALUH MERALDA

PER56/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6

1500000001603

KLINIK CITA MULIA

PERUM WIKARSA BLOK G NO1 KENANTEN PURI

61311

323302

CV GALUH MERALDA

PER/20/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

7

1500000001606

KLINIK EMMA

JL JETIS TAMA NO 3 GRIYA JETIS PERMAI

61352

CV BANGUN SESAMA DAMAI SEJAHTERA

PER/46/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1500000001606

KLINIK EMMA

JL JETIS TAMA NO 3 GRIYA JETIS PERMAI

61352

CV BANGUN SESAMA DAMAI SEJAHTERA

PER/24/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

9

1400000000107

KLINIK INDUSTRI MEDIKA

RUKO NGORO INDUSTRI PERSADA KAV A4A6

61385

6817979

MARIA MEILITASARI HARLIN DR, SPPD, MARS

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

10

1400000000107

KLINIK INDUSTRI MEDIKA

RUKO NGORO INDUSTRI PERSADA KAV A4A6

61385

6817979

MARIA MEILITASARI HARLIN DR, SPPD, MARS

PER/54/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001597

KLINIK KELUARGA BAHAGIA

JL RAYA BADUNG DSN BADUNG DS KEDUNGLENGKONG

61371

513355

NOVEL MOHAMMAD RAMZY PUTRA

PER/45/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000001597


JL RAYA BADUNG DSN BADUNG DS KEDUNGLENGKONG

61371

513355

NOVEL MOHAMMAD RAMZY PUTRA

PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

13

1500000001604

KLINIK MITRA 14 PERAK

DSN GADING DS GADINGMANGU KEC PERAK

61461

DR WARTIK

PER/51/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

1500000001604

KLINIK MITRA 14 PERAK

DSN GADING DS GADINGMANGU KEC PERAK

61461

DR WARTIK

PER/21/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


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255 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

15

1500000001607

KLINIK MITRA 39

JL RAYA DIWEK NO 39 KEC DIWEK

61471

DR BETTY ENDAH WARNI MKES

PER/23/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

16

1500000001607

KLINIK MITRA 39

JL RAYA DIWEK NO 39 KEC DIWEK

61471

DR BETTY ENDAH WARNI MKES

PER/53/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000001582

KLINIK POLRES JOMBANG

JL. KH. WAHID HASYIM NO 117

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

18

1500000001588

KLINIK POLRES KOTA MOJOKERTO

JL. BHAYANGKARA

PER/30/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

19

1500000001589

KLINIK POLRES MOJOKERTO

JL. BAYANGKARA NO. 25

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017

20

1500000001598

KLINIK PRATAMA MITRA 12

JL ANGGREK NO 24 CANDIMULYO

61411

878318

DR MERIDIAN GEODESI

PER/47/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1500000001598


JL ANGGREK NO 24 CANDIMULYO

61411

878318

DR MERIDIAN GEODESI

PER/15/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

22

1500000001605


JL PANGLIMA SUDIRMAN NO 26 KEC PLOSO

61453

DR WIWIET SARASWATI

PER/52/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1500000001605


JL PANGLIMA SUDIRMAN NO 26 KEC PLOSO

61453

DR WIWIET SARASWATI

PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

24

1500000001599


JL RAYA TROWULAN NO132 KEC TROWULAN

61362

492876

CV MITRA HUSADA

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

25

1500000001599


JL RAYA TROWULAN NO132 KEC TROWULAN

61362

492876

CV MITRA HUSADA

PER/49/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000001600


JL RAYA JETIS NO 14

61352

363786

IR H TEUKU ISMAIL

PER/17/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I

861843


SM0480



256 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

IR H TEUKU ISMAIL

PER/50/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

61384

SITI NUR HIDAYATI ST MKES

PER/44/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

61384


PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

YAYASAN PERMATA MOJOKERTO

PER/19/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

PER/32/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2017


PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

30/06/2015


PER/43/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

331234

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

JL GAJAHMADA NO 54

323252

PER/34/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

PUSKESMAS KEDUNDUNG

JL BY PASS KEDUNDUNG

392028

PER/33/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

1500000001585

PUSKESMAS MENTIKAN

JL PRAPANCA NO 55 PRAJURITKULON

321057

PER/35/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

1500000001583

PUSKESMAS WATES

JL LAWU RAYA NO 1 WATES

330144

PER/37/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

27

1500000001600


JL RAYA JETIS NO 14

61352

28

1500000001595

KLINIK PRATAMA SURYA HUSADA 2

JL RAYA PRAMBON DS NGIMBANG MOJOSARI

29

1500000001595

KLINIK PRATAMA SURYA HUSADA 2

JL RAYA PRAMBON DS NGIMBANG MOJOSARI

30

1500000001602

KLINIK RAWAT INAP IKFINA

JL RAYA PACING NO 27 KEC BANGSAL

31

1500000001581

KLINIK SPN MOJOKERTO

PULONITI, BANGSAL

32

1500000001596

KLINIK SURYA HUSADA

RAYA TRAWAS DSN WRINGINANOM DS MOJOREJO

61384

33

1500000001596

KLINIK SURYA HUSADA

RAYA TRAWAS DSN WRINGINANOM DS MOJOREJO

61384

34

1500000001584

PUSKESMAS BLOOTO

JL RAYA CINDE NO 3 PRAJURITKULON

35

1500000001586

PUSKESMAS GEDONGAN

36

1500000001587

37

38

MA11222I

363786

397355


SM0480



257 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

39

1500000001608

RS AL AZIZ

JL RAYA TEMBELANG KEC TEMBELANG

61453

853757

YAYASAN AL AZIZ

PER/25/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

40

1500000001608

RS AL AZIZ

JL RAYA TEMBELANG KEC TEMBELANG

61453

853757

YAYASAN AL AZIZ

PER/67/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

41

1400000000481

RS DHARMA HUSADA

JL RAYA NGORO 192

61385

6817833

HJ YUNI SETIJO SOEKORINI

PER/41/112015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

42

1400000000463

RS DR MOEDJITO DWIDJOSISWOJO

JL. HAYAM WURUK NO 9

61411

864308

PT MOEDJITO DWIDJOSISWOJO

PER/40/112015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

43

0900000000027

RS EMMA (RS TC)

JL RAYA IJEN NO 67

61311

032132873 7

DR MAGDALENA SITORUS

PER/05/012014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

44

0900000000027

RS EMMA (RS TC)

JL RAYA IJEN NO 67

61311

032132873 7

DR MAGDALENA SITORUS

PER/64/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

45

1500000000353

RS GATOEL

JL RADEN WIJAYA NO 56 KRANGGAN, PRAJURIT KULON

61319

328557


PER/07/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

46

1500000000353

RS GATOEL

JL RADEN WIJAYA NO 56 KRANGGAN, PRAJURIT KULON

61319

328557


PER/63/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

47

1500000000927

RS KAMAR MEDIKA

JL EMPUNALA NO 351 KEDUNDUNG MAGERSARI

330066

PT WAK KAMAR MEDIKA HOSPITAL

PER/65/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

48

1500000000927

RS KAMAR MEDIKA

JL EMPUNALA NO 351 KEDUNDUNG MAGERSARI

330066

PT WAK KAMAR MEDIKA HOSPITAL

PER/11/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

49

1400000000510

RS MAWADDAH MEDIKA

JL RAYA NGIJINGAN NGORO

61384

596666

PT WILUJENG ABADI SEJAHTERA

PER/42/112015

RS.TRAUMA CENTRE

22/12/2015

31/12/2016

50

1500000000925

RS MUTIARA HATI

JL RAYA KEMANTREN WETAN NO 49 TERUSAN GEDEG

61351

363442

SULFAKAR DR SPOG

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

MA11222I


SM0480



258 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

51

1500000000925

RS MUTIARA HATI

JL RAYA KEMANTREN WETAN NO 49 TERUSAN GEDEG

52

1500000001594

RS NAHDLATUL ULAMA JOMBANG

53

1500000001594

54

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

363442

SULFAKAR DR SPOG

PER/66/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL KH HASYIM ASYARI NO 211

878700

PT RUMAH SAKIT NAHDLATUL ULAMA JOMBANG

PER/69/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

RS NAHDLATUL ULAMA JOMBANG

JL KH HASYIM ASYARI NO 211

878700

PT RUMAH SAKIT NAHDLATUL ULAMA JOMBANG

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

1500000001522

RS PELENGKAP MEDICAL CENTER

JL IR JUANDA NO 03

61411

877945

PT PELANGKAP MEDICA SEJAHTERA

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

55

1500000001522

RS PELENGKAP MEDICAL CENTER

JL IR JUANDA NO 03

61411

877945

PT PELANGKAP MEDICA SEJAHTERA

PER/68/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

56

0800000000011

RS SIDO WARAS (RS TC)

JL RAYA PASAR SAWAHAN KM 10 BANGSAL

61381

598621

DR MARIA M HARLIM SP.PD

PER/60/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

57

0800000000011

RS SIDO WARAS (RS TC)

JL RAYA PASAR SAWAHAN KM 10 BANGSAL

61381

598621

DR MARIA M HARLIM SP.PD

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

58

0800000000034

RSI AROFAH (RS TC)

JL. GAJAH MADA NO.1 MOJOSARI

61382

596900

DR HR SETIOHARTONO

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

59

0800000000034

RSI AROFAH (RS TC)

JL. GAJAH MADA NO.1 MOJOSARI

61382

596900

DR HR SETIOHARTONO

PER/62/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

60

1500000001523

RSI HASANAH

JL HOS COKROAMINOTO NO 26-28 MOJOKERTO

321635

PIMPINAN WILAYAH MUHAMMADIYAH JAWA TIMUR

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

61

1500000001523

RSI HASANAH

JL HOS COKROAMINOTO NO 26-28 MOJOKERTO

321635

PER/70/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

62

1500000001621

RSI JOMBANG

JL BRIGJEN KRETARTO NO 22 A

PER/58/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

MA11222I

61351

61411

860074

PIMPINAN WILAYAH MUHAMMADIYAH JAWA TIMUR YAYASAN AMAL SHOLEH IKATAN PERSAUDARAAN HAJI INDONESIA


SM0480



259 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

63

1500000001621

RSI JOMBANG

JL BRIGJEN KRETARTO NO 22 A

61411

860074

YAYASAN AMAL SHOLEH IKATAN PERSAUDARAAN HAJI INDONESIA

PER/38/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

64

0800000000033

RSI SAKINAH (RS TC)

JL R A BASUNI NO 12

61361

321922

DR SULAIMAN ROSYID

PER/61/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

65

0800000000033

RSI SAKINAH (RS TC)

JL R A BASUNI NO 12

61361

321922

DR SULAIMAN ROSYID

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

66

1500000001623

RSU KARTINI

JL AIRLANGGA NO 37 MOJOSARI

592261

YAYASAN KARTINI

PER/39/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

67

0800000000010

RSUD. PROF. DR. SOEKANDAR (RS TC)

JL HAYAM WURUK NO 25 MOJOSARI

61382

591591

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

68

0800000000010

RSUD. PROF. DR. SOEKANDAR (RS TC)

JL HAYAM WURUK NO 25 MOJOSARI

61382

591591

PER/59/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

69

1500000000347

RUMAH SAKIT KRISTEN MOJOWARNO

JL MERDEKA NO 59 MOJOWARNO

61475

495093

YAYASAN KESEHATAN GKJW

PER/08/032015

RS.TRAUMA CENTRE

01/03/2015

31/12/2015

70

1500000000347

RUMAH SAKIT KRISTEN MOJOWARNO

JL MERDEKA NO 59 MOJOWARNO

61475

495093

YAYASAN KESEHATAN GKJW

PER/57/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1500000001578

MA11222I

:

N06- KANTOR CABANG BANYUWANGI

NAMA PROVIDER

BALAI PENGOBATAN POLRES BANYUWANGI

ALAMAT

JL. LETKOL ISTIQLAH NO. 53

KODE POS

IKS TELEPON

PIMPINAN NO IKS

421060

PER/06/062015



AWAL IKS 22/06/2015


SM0480



260 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

2

1500000001577

BALAI PENGOBATAN POLRES SITUBONDO

JALAN PB. SUDIRMAN NO. 30, KEC. SITUBONDO

3

1500000000827

KLINIK BRAWIJAYA

JL BRAWIJAYA NO 46 KEBALENAN

423711

4

1500000000827

KLINIK BRAWIJAYA

JL BRAWIJAYA NO 46 KEBALENAN

5

1500000000832

KLINIK KHADIJAH PKU MUHAMMADIYAH MUNCAR

6

1500000000832

7

TIPE IKS

AWAL IKS

AKHIR IKS

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

31/12/2015

DR EDI HERMANTO

PER/07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

423711

DR EDI HERMANTO

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

JL BRAWIJAYA 23A MUNCAR

592890

PIMPINAN CABANG MUHAMMADIYAH MUNCAR

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

KLINIK KHADIJAH PKU MUHAMMADIYAH MUNCAR

JL BRAWIJAYA 23A MUNCAR

592890

PIMPINAN CABANG MUHAMMADIYAH MUNCAR

PER/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1400000000367

RS AL HUDA

JL RAYA GAMBIRAN 225 GENTENG

842033

YYS NURUL HUDA

PER/16/102015

RS.TRAUMA CENTRE

28/12/2015

31/12/2016

8

1200000000005

RS YASMIN

JL LETKOL ISTIQLAH 80-84

421198

YAYASAN SUMBER WARAS

PER/18/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

9

1200000000005

RS YASMIN

JL LETKOL ISTIQLAH 80-84

421198

YAYASAN SUMBER WARAS

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1400000000010

RSU BHAKTI HUSADA KRIKILAN

KRIKILAN GLENMORE

821118


PER/19/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

11

1400000000010

RSU BHAKTI HUSADA KRIKILAN

KRIKILAN GLENMORE

821118


PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000001552

RSUD ASEMBAGUS SITUBONDO

JL RAYA ASEMBAGUS KECAMATAN ASEMBAGUS

452193

PER/09/052015

RS.TRAUMA CENTRE

22/06/2015

31/12/2015

13

1500000001552

RSUD ASEMBAGUS SITUBONDO

JL RAYA ASEMBAGUS KECAMATAN ASEMBAGUS

452193

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


SM0480



261 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

14

1500000001392

RSUD BESUKI

JL OLAHRAGA NO 55 BESUKI

891118

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

15

1500000001392

RSUD BESUKI

JL OLAHRAGA NO 55 BESUKI

891118

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

1400000000672

RSUD BLAMBANGAN BANYUWANGI

JL LETKOL ISTIQLAH BANYUWANGI

421118

PEMDA BANYUWANGI

PER/20/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

17

1400000000672

RSUD BLAMBANGAN BANYUWANGI

JL LETKOL ISTIQLAH BANYUWANGI

421118

PEMDA BANYUWANGI

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

18

1400000000470

RSUD DR ABDOER RAHEM

JL ANGGREK 68

671028

PEMDA SITUBONDO

PER/17/122015

RS.TRAUMA CENTRE

28/12/2015

31/12/2016

19

1500000000826

RSUD GENTENG BANYUWANGI

JL HASANUDDIN NO 98 GENTENG

845839

PER/05/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

20

1500000000826

RSUD GENTENG BANYUWANGI

JL HASANUDDIN NO 98 GENTENG

845839

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1500000001576

UPT PELATIHAN KERJA SITUBONDO


672054

PER/10/062015

RS.TRAUMA CENTRE

22/06/2015

31/12/2015

22

1500000001576

UPT PELATIHAN KERJA SITUBONDO


672054

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

MA11222I

:

N07- KANTOR CABANG MADIUN


SM0480



262 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001665

BIDDOKKES POLRES MADIUN

JL. SOEKARNO-HATTA NO.66

459725

PER/068/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

2

1500000001670

BIDDOKKES POLRESTA MADIUN

JL SUMETERA NO 28

465455

PER/069/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

3

1500000000857

KLINIK BP BHAKTI RAHAYU

JL THAMRIN NO 99 MADIUN

462439

PER/32/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

4

1500000000786

PUSKESMAS BALEREJO

JL RAYA MADIUN SURABAYA NO 82 DS BALEREJO KEC BALEREJO

383798

PER/46/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

5

1500000000774

PUSKESMAS BANGUNSARI

JL PANJANG PUNJUNG DS DOLOPO KEC.DOLOPO

368601

PER/34/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

6

1500000000938

PUSKESMAS BANJAREJO

JL. BAYANGKARA NO.1 KEL BANJAREJO KEC. TAMAN

456322

PER/60/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

7

1500000000780

PUSKESMAS DAGANGAN

JL RAYA DAGANGAN PAGOTAN NO 57 DS DAGANGAN KEC DAGANGAN

367079

PER/40/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

8

1500000000939

PUSKESMAS DEMANGAN

JL. SOEKARNO HATTA NO. 47 KEL. DEMANGAN KEC. TAMAN

464308

PER/61/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

9

1500000000784

PUSKESMAS DIMONG

JL RAYA DIMONG DS DIMONG KEC MADIUN

458123

PER/44/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

10

1500000000777

PUSKESMAS GANTRUNG

JL RAYA DOLOPO DS SIDOREJO KEC.KEBONSARI

367743

PER/37/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1500000000778

PUSKESMAS GEGER

JL RAYA PONOROGO NO 48 DS PURWOREJO KEC GEGER

367158

PER/38/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

12

1500000000794

PUSKESMAS GEMARANG

JL TGP NO 17 DS GEMARANG KEC GEMARANG

PER/54/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I

CV BHAKTI NADINA CORPORATE


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000000781

PUSKESMAS JETIS

JL JETIS DS JETIS KEC DAGANGAN

367664

PER/41/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

14

1500000000782

PUSKESMAS JIWAN

JL RAYA SOLO NO 85 DS JIWAN KEC.JIWAN

465023

PER/42/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

15

1500000000779

PUSKESMAS KAIBON

JL PANCOTARUNO NO 407 DS KAIBON KEC GEGER

455636

PER/39/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

16

1500000000795

PUSKESMAS KARE

JL RAYA RANDU ALAS KARE KEC KARE

3406616

PER/55/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

17

1500000000776

PUSKESMAS KEBONSARI

JL UTERAN KEBONSARI NO 13 DS SINGGAHAN KEC KEBONSARI

367991

PER/36/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

18

1500000000799

PUSKESMAS KLAGENSERUT

JL RAYA KLAGEN SERUT KEC JIWAN

499761

PER/59/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

19

1500000000798

PUSKESMAS KLECOREJO

JL RAYA WATES DS KLECOREJO KEC MEJAYAN

388155

PER/58/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

20

1500000000791

PUSKESMAS KREBET

JL GAWANG UTARA DS KREBET KEC.PILANGKENCENG

PER/51/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

21

1500000000783

PUSKESMAS MADIUN

JL RAYA PUSKESMAS NO 9 DS TIRON KEC MADIUN

458271

PER/43/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

22

1500000000936

PUSKESMAS MANGUHARJO

JL. GAJAHMADA NO. 124 KEL. MANGUHARJO KEC. MANGUHARJO

464661

PER/64/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

23

1500000000789

PUSKESMAS MEJAYAN

JL PANGLIMA SUDIRMAN NO 52 DS MEJAYAN KEC.MEJAYAN

384543

PER/49/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

24

1500000000775

PUSKESMAS MLILIR

JL RAYA MADIUN PONOROGO NO 06 MLILIR KEC DLOPO

368098

PER/35/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

25

1500000000797

PUSKESMAS MOJOPURNO

JL RAYA DUNGUS DS MOJOPURNO KEC WUNGU

26

1500000000934

PUSKESMAS ORO - ORO OMBO

JL. DIPONEGORO NO. 22 KEL. ORO-ORO OMBO KEC KARTOHARJO

27

1500000000937

PUSKESMAS PATIHAN

28

1500000000790

29

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/57/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

464402

PER/62/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

JL. MENDUT NO.1 KEL. PATIHAN KEC. MANGUHARJO

462272

PER/65/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PUSKESMAS PILANG KENCENG

JL RAYA KENONGO REJO NO 774B DS KENONGOREJO KEC PILANGKENCENG

383536

PER/50/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

1500000000792

PUSKESMAS SARADAN

JL RAYA SARADAN DS SUGIHWARAS KEC SARADAN

PER/52/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

30

1500000000785

PUSKESMAS SAWAHAN

JL RAYA KAJANG DS KAJANG KEC SAWAHAN

468434

PER/45/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

31

1500000000787

PUSKESMAS SIMO

JL RAYA BALEREJO-MUNENG NO 96 DS SIMO KEC BALEREJO

661631

PER/47/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

32

1500000000793

PUSKESMAS SUMBERSARI

JL RAYA TULUNG NO 05 DS SUMBERSARI KEC SARADAN

384456

PER/53/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

33

1500000000935

PUSKESMAS TAWANGREJO

JL. TAWANGSARI NO. 39 KEL. TAWANGREJO KEC. KARTOHARJO

483997

PER/63/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

34

1500000000788

PUSKESMAS WONOASRI

RAYA WONOASRI DS WONOASRI KEC WONOASRI

PER/48/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

35

1500000000796

PUSKESMAS WUNGU

JL RAYA KARE NO 113 DS WUNGU KEC WUNGU

494048

PER/56/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

36

1400000000150

RSI SITI AISYAH MADIUN

JL MAYJEND SUNGKONO NO 38

464822

PER/82/102015

RS.TRAUMA CENTRE

31/12/2015

30/04/2016

MA11222I

PP MUHAMMADIYAH


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

37

1400000000149

RSU DARMAYU

JL. DR. SUTOMO NO. 44

38

1500000001809

RUMAH SAKIT ISLAM ATTIN HUSADA NGAWI

JL RAYA NGAWI - SOLO KM 4 WATUALUNG

39

1500000001246

UPT PELATIHAN KERJA CARUBAN MADIUN

JL SUMATERA NO 27 CARUBAN MADIUN

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

63252

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

481320

PT DARMAYU PURI KENCANA

PER/00X/042015

RS.TRAUMA CENTRE

29/12/2015

30/04/2016

747888

HJ SRI YATIN SE

PER/69/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

PER/33/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

383166

N08- KANTOR CABANG BLITAR

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001631

POLRES BLITAR

JALAN RAYA TALUN NO 88

POLRES BLITAR

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2016

2

1500000001632

POLRES KOTA BLITAR

JL. P. SUDIRMAN 32

POLRES KOTA BLITAR

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2016

3

1500000001629

POLRES TRENGGALEK

JL. PANGLIMA SUDIRMAN 42

POLRES TRENGGALEK

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2016

4

1500000001630

POLRES TULUNGAGUNG

JL. AHMAD YANI TIMUR NO 9

POLRES TULUNGAGUNG

PER/06/062015

RS.TRAUMA CENTRE

22/06/2015

21/06/2016

5

1500000001915

RS SYUHADA HAJI

JL TANJUNG NO 158

801607

YAYASAN MONUMEN SYUHADA HAJI

PER/03/062015

RS.TRAUMA CENTRE

25/06/2015

24/06/2017

6

1500000000224

RSU ISLAM ORPEHA TULUNGAGUNG

JL KHR ABDUL FATAH DS. BATANGSAREN KEC. KAUMAN

323186

R. H LAITUPA ABDULMUTALIB

PER/01/012015

RS.TRAUMA CENTRE

01/02/2015

31/01/2017

MA11222I

66122


SM0480



266 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

7-1579046012

RSUD MARDI WALUYO

JL KALIMANTAN NO 113

66133

(0342)8011 18

PEMKOT BLITAR

PER/02/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

8

7-1575901783

RSUD NGUDI WALUYO WLINGI

JL DR SOECIPTO NO 5

66184

034269100 6

PEMKAB BLITAR

PER/01/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

9

1500000000831

RUMAH SAKIT BHAYANGKARA TULUNGAGUNG

JL I GUSTI NGURAH RAI NO.25-27

321203

DR. SUMARSONO, SP.RAD, MM

PER/02/052015

RS.TRAUMA CENTRE

05/05/2015

04/05/2017

KANTOR CABANG

NO

KODE PROVIDER

:

N09- KANTOR CABANG MADURA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001625

FASKES POLRES BANGKALAN

JL SOEKARNO HATTA KECAMATAN BANGKALAN

PER/08/062015

RS.TRAUMA CENTRE

22/06/2015

30/06/2017

2

1500000001627

FASKES POLRES PAMEKASAN

JL RY DESA TEJA NO. 131

PER/07/062015

RS.TRAUMA CENTRE

22/06/2015

30/06/2017

3

1500000001624

FASKES POLRES SAMPANG

KARANG DALEM KECAMATAN SAMPANG

PER/09/062015

RS.TRAUMA CENTRE

22/06/2015

30/06/2017

4

1500000001626

FASKES POLRES SUMENEP

JL URIP SUMOHARJO 35

PER/10/062015

RS.TRAUMA CENTRE

22/06/2015

30/06/2017

5

1500000001553

KLINIK PRATAMA AN NUR

JL RY PALDUDING KM 10 DS PLAKPAK KEC PEGANTENAN

DR H ACHMAD FURQON

PER/06/062015

RS.TRAUMA CENTRE

24/06/2015

30/06/2016

6

1400000000233

PUSKESMAS TLANAKAN

JL RAYA TLANAKAN PAMEKASAN

PUSKESMAS

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

325568


SM0480



267 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

1400000000233

PUSKESMAS TLANAKAN

JL RAYA TLANAKAN PAMEKASAN

325568

PUSKESMAS

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

8

1400000000437

RS LUKAS BANGKALAN

JL KH MOCH KHOLIL 36A BANGKALAN

3095148

PHILIP

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1400000000436

RSUD DR H MOH ANWAR SUMENEP

JL DR CIPTO NO 42 SUMENEP

662494

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1500000000633

RSUD DR H SLAMET MARTODIRJO PAMEKASAN

326242

PER/03/042015

RS.TRAUMA CENTRE

27/04/2015

30/04/2016

11

1500000000235

RSUD SAMPANG

JL RAJAWALI NO 10

323956

PER/02/022015

RS.TRAUMA CENTRE

25/02/2015

31/12/2015

12

1500000000235

RSUD SAMPANG

JL RAJAWALI NO 10

323956

PER/02/022016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1400000000520

RSUD SYARIFAH AMBAMI RATO EBO BANGKALAN

JL PEMUDA KAFFA NO. 9 BANGKALAN

3095088

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

N10- KANTOR CABANG BOJONEGORO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000753

BP MITRA 30

JL. BOJONEGORO NO 51 BANARAN BABAT

451058

IR T ISMAIL

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

2

1500000000800

BP MITRA 5

JL DR CIPTO NO 129

892665

IR T ISMAIL

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

1500000000752

BP MITRA 6

JL WR SUPRATMAN NO 35

321394

IR T ISMAIL

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

4

1500000000751

BP MITRA 8

JL ANDANWANGI NO 43

7722188

IR T ISMAIL

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

5

1500000001638

DOKKES POLRES BOJONEGORO

JL MH THAMRIN NO. 46 BOJONEGORO JAWA TIMUR

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

6

1500000001636

DOKKES POLRES LAMONGAN

JL. KBP DURYAT LAMONGAN

PER/17/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

7

1500000001633

DOKKES POLRES TUBAN

JL DR WAHIDIN SH TUBAN JAWA TIMUR

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

8

1400000000538

RS BHAYANGKARA WAHYU TUTUKO BOJONEGORO

JL PANGLIMA SUDIRMAN NO 168-169

888786

KOMPOL. DR. BAYU DHARMA SHANTI SP.PD

PER/10/122014

RS.TRAUMA CENTRE

21/12/2015

31/12/2016

9

1300000000045

RS DR. SUYUDI PACIRAN LAMONGAN

JL RAYA DEANDELES KECAMATAN PACIRAN

661412

DR DENNY AVIANTO SPD

PER/20/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1300000000045

RS DR. SUYUDI PACIRAN LAMONGAN

JL RAYA DEANDELES KECAMATAN PACIRAN

661412

DR DENNY AVIANTO SPD

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

11

1300000000047

RS NAHDLATUL ULAMA (NU) TUBAN

JL LETDA SUCIPTO NO 211

328244

DR DIDIK SUHARSOYO MM MARS

PER/01/01215

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

12

1300000000047

RS NAHDLATUL ULAMA (NU) TUBAN

JL LETDA SUCIPTO NO 211

328244

DR DIDIK SUHARSOYO MM MARS

PER/21/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000000747

RSUD. DR. KOESMA TUBAN

JL WAHIDIN SUDIRO HUSODO NO 800

321010

DR. H ZAINUL ARIFIN, SPPK

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

14

1500000000517

RSUD.DR.SOEGIRI. LAMONGAN

JL. KUSUMA BANGSA NO.7

321718

DR. YULIARTO DWI MARTONO, MMKES

PER/4/042015445/352/413.209/ 2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I


SM0480



269 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

15

1500000001403

RUMAH SAKIT ISLAM MUHAMMADIYAH SUMBERREJO BOJONEGORO

JL. RAYA SUMBERREJO NO.1193 SUMBERREJO

331056

DR.H.TOMY OEKY PRASISKA

PER/15/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1500000001402

RUMAH SAKIT KHUSUS BEDAH "PEMUDA" BOJONEGORO

JL. PEMUDA NO. 29

887749

DR.M.NAQVI ALFARISI

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

NO

KODE PROVIDER

:

N11- KANTOR CABANG SIDOARJO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000354

KLINIK CENDEKIA HUSADA

JL RAYA LINGKAR TIMUR RANGKAH KIDUL

8944584

DR DRS H SOEHARTO SH

PER/12/032015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

2

1400000000600

KLINIK CITRA GADING MEDIKA

JL BRIGJEND KATAMSO A408-409 REWWIN WARU

8679727

IR SAD INDAH AMBARWATI

PER/19/122015

RS.TRAUMA CENTRE

21/12/2015

30/11/2016

3

1500000000917

KLINIK HABIBAH

JL RAYA CANGKRING RT 07 RW 02 KREMBUNG

8856706

DR WIWIK SETYORINI

PER/15/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

4

1500000000918

KLINIK HABIBAH 2

DS PILANG BANGU RT 08 RW 03 BALONG BENDO

8979631

DR WIWIK SETYORINI

PER/15/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

5

1500000001652

KLINIK POLRES SIDOARJO

JL KOMBES POL MOH DURYAT 45

PER/06/062016

RS.TRAUMA CENTRE

22/06/2015

21/06/2017

6

1500000000172

KLINIK PRATAMA RAWAT JALAN & RAWAT INAP "BDS TEBEL" 24 JAM

JL TEBEL BARAT NO 1-3

8911555

PER/08/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

7

1500000000605

KRIYANDAS NURANI

JL RAYA KEBONAGUNG NO 48 SUKODONO

58834697

PER/13/042015

FFS

01/04/2015

31/03/2016

MA11222I

CV NURANI


SM0480



270 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

1500000001401

PUSKESMAS BALONGBENDO

JL MAYJEN BAMBANG SUWONO NO 11 SEDURI

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1500000001401

PUSKESMAS BALONGBENDO

JL MAYJEN BAMBANG SUWONO NO 11 SEDURI

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

10

1500000001372

PUSKESMAS BARENGKRAJAN

DS BARENGKRAJAN KEC KRIAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001372

PUSKESMAS BARENGKRAJAN

DS BARENGKRAJAN KEC KRIAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001363

PUSKESMAS BUDURAN

JL JAWA NO 2 KEC BUDURAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000001363

PUSKESMAS BUDURAN

JL JAWA NO 2 KEC BUDURAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

14

1500000001354

PUSKESMAS CANDI

JL M RIDWAN NO 5 GELAM KEC CANDI

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

15

1500000001354

PUSKESMAS CANDI

JL M RIDWAN NO 5 GELAM KEC CANDI

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

1500000001368

PUSKESMAS GANTING

JL SINGO MENGGOLO NO 1 DS GANTING

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000001368

PUSKESMAS GANTING

JL SINGO MENGGOLO NO 1 DS GANTING

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

18

1500000001367

PUSKESMAS GEDANGAN

JL RAYA GEDANGAN 330 KEC GEDANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

19

1500000001367

PUSKESMAS GEDANGAN

JL RAYA GEDANGAN 330 KEC GEDANGAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


SM0480



271 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

20

1500000001352

PUSKESMAS JABON

JL DUKUH SARI KEC JABON

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

21

1500000001352

PUSKESMAS JABON

JL DUKUH SARI KEC JABON

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

1500000001346

PUSKESMAS KEDUNG SOLO

DS KEDUNG SOLO KEC PORONG

PER/16/062016

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

23

1500000001346

PUSKESMAS KEDUNG SOLO

DS KEDUNG SOLO KEC PORONG

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1500000001356

PUSKESMAS KEPADANGAN

DS KEPADANGAN KEC TULANGAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

25

1500000001356

PUSKESMAS KEPADANGAN

DS KEPADANGAN KEC TULANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000001344

PUSKESMAS KREMBUNG

JL SUNGAI KAPUAS NO 2 KEC KREMBUNG

PER/16/062016

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

27

1500000001344

PUSKESMAS KREMBUNG

JL SUNGAI KAPUAS NO 2 KEC KREMBUNG

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

1500000001371

PUSKESMAS KRIAN

JL SETIA BUDI KEC KRIAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

29

1500000001371

PUSKESMAS KRIAN

JL SETIA BUDI KEC KRIAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

30

1500000001366

PUSKESMAS MEDAENG

JL JOYOBOYO 40 MEDAENG KEC WARU

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

31

1500000001366

PUSKESMAS MEDAENG

JL JOYOBOYO 40 MEDAENG KEC WARU

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


SM0480



272 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

32

1500000001345

PUSKESMAS PORONG

JL JUWET UTARA 265 KEC PORONG

PER/16/062016

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

33

1500000001345

PUSKESMAS PORONG

JL JUWET UTARA 265 KEC PORONG

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

34

1500000001343

PUSKESMAS PRAMBON

JL RAYA PRAMBAON KEC PRAMBON

PER/16/062016

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

35

1500000001343

PUSKESMAS PRAMBON

JL RAYA PRAMBAON KEC PRAMBON

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

36

1500000001364

PUSKESMAS SEDATI

DS BETRO KEC SEDATI

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

37

1500000001364

PUSKESMAS SEDATI

DS BETRO KEC SEDATI

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

1500000001361

PUSKESMAS SEKARDANGAN

JL WIJAYA KUSUMA NO 91 SEKARDANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

39

1500000001361

PUSKESMAS SEKARDANGAN

JL WIJAYA KUSUMA NO 91 SEKARDANGAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

40

1500000001359

PUSKESMAS SIDOARJO

JL DR SOETOMO NO 14 KEC SIDOARJO

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

41

1500000001359

PUSKESMAS SIDOARJO

JL DR SOETOMO NO 14 KEC SIDOARJO

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

42

1500000001358

PUSKESMAS SUKODONO

DS PEKARUNGAN KEC SUKODONO

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

43

1500000001358

PUSKESMAS SUKODONO

DS PEKARUNGAN KEC SUKODONO

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


SM0480



273 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

44

1500000001369

PUSKESMAS TAMAN

JL RAYA NGELOM 50 KEC TAMAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

45

1500000001369

PUSKESMAS TAMAN

JL RAYA NGELOM 50 KEC TAMAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

46

1500000001353

PUSKESMAS TANGGULANGIN

JL RAYA PUTAT NO 38 KEC TANGGULANGIN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

47

1500000001353

PUSKESMAS TANGGULANGIN

JL RAYA PUTAT NO 38 KEC TANGGULANGIN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

48

1500000001342

PUSKESMAS TARIK

JL RAYA KEMUNING KEC TARIK

PER/16/062016

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

49

1500000001342

PUSKESMAS TARIK

JL RAYA KEMUNING KEC TARIK

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

50

1500000001370

PUSKESMAS TROSOBO

JL RAYA TROSOBO KEC TAMAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

51

1500000001370

PUSKESMAS TROSOBO

JL RAYA TROSOBO KEC TAMAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

52

1500000001355

PUSKESMAS TULANGAN

JL RAYA KEMANTREN KEC TULANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

53

1500000001355

PUSKESMAS TULANGAN

JL RAYA KEMANTREN KEC TULANGAN

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

54

1500000001360

PUSKESMAS URANGAGUNG

JL RAYA CEMENG KALANG KEC SIDOARJO

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

55

1500000001360

PUSKESMAS URANGAGUNG

JL RAYA CEMENG KALANG KEC SIDOARJO

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


SM0480



274 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

56

1500000001365

PUSKESMAS WARU

JL BARITO POJOK NO 1 WISTROP KEC WARU

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

57

1500000001365

PUSKESMAS WARU

JL BARITO POJOK NO 1 WISTROP KEC WARU

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

58

1500000001357

PUSKESMAS WONOAYU

JL WONOAYU KEC WONOAYU

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

59

1500000001357

PUSKESMAS WONOAYU

JL WONOAYU KEC WONOAYU

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

60

1400000000563

RS BHAYANGKARA PUSDIK GASUM PORONG

JL RAYA PORONG NO 1

852104

POLRI

PER/18/122015

RS.TRAUMA CENTRE

21/12/2015

30/11/2016

61

1400000000128

RS BUNDA SIDOARJO

JL KUNDI NO 70 KEPUH KIRIMAN WARU

8668880

PT PERMATA BUNDA BERSAMA

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

62

1400000000128

RS BUNDA SIDOARJO

JL KUNDI NO 70 KEPUH KIRIMAN WARU

8668880


PER/25/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

63

0800000000036

RS CITRA MEDIKA

JL.RAYA SURABAYA-MOJOKERTO KM 44

361000

PER/21/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

64

0800000000036

RS CITRA MEDIKA

JL.RAYA SURABAYA-MOJOKERTO KM 44

361000

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

65

1500000000736

RS ISLAM SITI HAJAR

JL RADEN PATAH 70-72

8921233

BPM NU SITI HAJAR

PER/14/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

66

1300000000030

RS SITI KHODIJAH

JL PAHLAWAN NO 260 SEPANJANG

7882123

YYS MUHAMMADIYAH

PER/23/12205

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

67

1300000000030

RS SITI KHODIJAH

JL PAHLAWAN NO 260 SEPANJANG

7882123

YYS MUHAMMADIYAH

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


SM0480



275 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

68

1400000000278

RSU ANWAR MEDIKA

JL RAYA BY PASS KRIAN KM 33 BALONGBENDO

8974943

YAYASAN RUMAH SAKIT ANWAR MEDIKA

PER/22/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

69

1400000000278

RSU ANWAR MEDIKA

JL RAYA BY PASS KRIAN KM 33 BALONGBENDO

8974943

YAYASAN RUMAH SAKIT ANWAR MEDIKA

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

70

1200000000014

RSU JASEM

JL KH SAMANHUDI NO 85

8962129

YAYASAN USADA KARYA

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

71

1200000000014

RSU JASEM

JL KH SAMANHUDI NO 85

8962129

YAYASAN USADA KARYA

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

72

0700000000008

RSUD SIDOARJO

JL MAJAPAHIT NO 667

8961649

PER/20/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

73

0700000000008

RSUD SIDOARJO

JL MAJAPAHIT NO 667

8961649

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

N12- KANTOR CABANG GRESIK

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000811

BP PANGLIMA SUDIRMAN GRESIK

JL PANGLIMA SUDIRMAN

085631864 35

YUNI HIDAYATI

PER/12/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1500000000811

BP PANGLIMA SUDIRMAN GRESIK

JL PANGLIMA SUDIRMAN

085631864 35

YUNI HIDAYATI

PER/12/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

3

1500000001618

FKTP POLRES GRESIK

JL BASUKI RAHMAT 2 GRESIK

DR. BUDIYONO, MARS

PER/14/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


SM0480



276 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. BUDIYONO, MARS

PER/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

085631864 35

YUNI HIDAYATI

PER/11/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

MANYAR RESORT

085631864 35

YUNI HIDAYATI

PER/11/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016


JL. RAYA WRINGINANOM KM.33.6

81180888

NOVEL MUHAMMAD RAMZY

PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1500000000893

PUSKESMAS ALUN ALUN GRESIK

JL. PAHLAWAN GRESIK

3981865

DR. ACH SYAFI'I

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1500000000893

PUSKESMAS ALUN ALUN GRESIK

JL. PAHLAWAN GRESIK

3981865

DR. ACH SYAFI'I

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

10

1500000001569

PUSKESMAS BALONGPANGGANG GRESIK

RAYA KEDUNGPRING 8 BALONGPANGGANG GRESIK

7921007

DR RINI SULISTYOASIH

PER/05/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001569

PUSKESMAS BALONGPANGGANG GRESIK

RAYA KEDUNGPRING 8 BALONGPANGGANG GRESIK

7921007

DR RINI SULISTYOASIH

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

12

1500000001572

PUSKESMAS BENJENG GRESIK

JL. RAYA NYAYAT 34 BENJENG GRESIK

7921167

DR SONY

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000001572

PUSKESMAS BENJENG GRESIK

JL. RAYA NYAYAT 34 BENJENG GRESIK

7921167

DR SONY

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

14

1500000001492

PUSKESMAS BUNGAH GRESIK

JL RAYA BUNGAH 15 GRESIK

3949600

DRG TITY KARYATI PANIGORO

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

15

1500000001492

PUSKESMAS BUNGAH GRESIK

JL RAYA BUNGAH 15 GRESIK

3949600

DRG TITY KARYATI PANIGORO

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1500000001618

FKTP POLRES GRESIK

JL BASUKI RAHMAT 2 GRESIK

5

1500000000810

KLINIK HIDAYAH MANYAR

MANYAR RESORT

6

1500000000810

KLINIK HIDAYAH MANYAR

7

1400000000627

8

MA11222I


SM0480



277 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1500000000757

PUSKESMAS CERME GRESIK

JL RAYA CERME KIDUL 52 CERME

7990007

DR LESTARI

PER/05/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000000757

PUSKESMAS CERME GRESIK

JL RAYA CERME KIDUL 52 CERME

7990007

DR LESTARI

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

18

1500000001573

PUSKESMAS DADAP KUNING GRESIK

JL. RAYA DADAP KUNING 32 GRESIK

7990510

DR GATOT PURNOMO

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

19

1500000001573

PUSKESMAS DADAP KUNING GRESIK

JL. RAYA DADAP KUNING 32 GRESIK

7990510

DR GATOT PURNOMO

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1500000001570

PUSKESMAS DAPET GRESIK

RAYA TANAH LENDEAN 49 BALONGPANGGANG GRESIK

70953980

DR SOESILO

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

21

1500000001570

PUSKESMAS DAPET GRESIK

RAYA TANAH LENDEAN 49 BALONGPANGGANG GRESIK

70953980

DR SOESILO

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

1500000000741

PUSKESMAS DRIYOREJO GRESIK

RAYA DRIYOREJO GRESIK

23264794

DR DANIEL SA'U

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

23

1500000000741

PUSKESMAS DRIYOREJO GRESIK

RAYA DRIYOREJO GRESIK

23264794

DR DANIEL SA'U

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1500000001571

PUSKESMAS DUDUK SAMPEYAN GRESIK

RAYA DUDUK SAMPEYAN 45 DUDUK SAMPEYAN GRESIK

3903118

DRG NANIK LESTARI

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

25

1500000001571

PUSKESMAS DUDUK SAMPEYAN GRESIK

RAYA DUDUK SAMPEYAN 45 DUDUK SAMPEYAN GRESIK

3903118

DRG NANIK LESTARI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000001489

PUSKESMAS DUKUN GRESIK

JL RAYA SEMBUNGAN KIDUL 37 DUKUN GRESIK

3949299

DRG SAIFUDIN GOZALI

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

27

1500000001489

PUSKESMAS DUKUN GRESIK

JL RAYA SEMBUNGAN KIDUL 37 DUKUN GRESIK

3949299

DRG SAIFUDIN GOZALI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

28

1500000000742

PUSKESMAS GENDING GRESIK

JL VETERAN GRESIK

3985872

DRG HELENA SUZANA

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

29

1500000000742

PUSKESMAS GENDING GRESIK

JL VETERAN GRESIK

3985872

DRG HELENA SUZANA

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

30

1500000000892

PUSKESMAS INDUSTRI GRESIK

JL. ARIEF RAHMAN HAKIM 100 GRESIK

3985877

DRG ANISAH MAHMUDAH

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

31

1500000000892

PUSKESMAS INDUSTRI GRESIK

JL. ARIEF RAHMAN HAKIM 100 GRESIK

3985877

DRG ANISAH MAHMUDAH

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

32

1500000000890

PUSKESMAS KARANGANDONG GRESIK

RAYA KARANGANDONG DRIYOREJO GRESIK

7911659

DR SITI HAFIDA

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

1500000000890

PUSKESMAS KARANGANDONG GRESIK

RAYA KARANGANDONG DRIYOREJO GRESIK

7911659

DR SITI HAFIDA

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

34

1500000000894

PUSKESMAS KEBOMAS GRESIK

JL SUNAN GIRI III/1 GRESIK

3985880

DR. RAHAJU NUGRAHANI

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

35

1500000000894

PUSKESMAS KEBOMAS GRESIK

JL SUNAN GIRI III/1 GRESIK

3985880

DR. RAHAJU NUGRAHANI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

36

1500000000755

PUSKESMAS KEDAMEAN GRESIK

RAYA KEDAMEAN NO 1 GRESIK

7911437

DR. HILDA BETSY

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

37

1500000000755

PUSKESMAS KEDAMEAN GRESIK

RAYA KEDAMEAN NO 1 GRESIK

7911437

DR. HILDA BETSY

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

1500000001565

PUSKESMAS KEPATIHAN GRESIK

RAYA KEPATIHAN 151

7991403

DRG TITIEK SRI HAJATI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

39

1500000001565

PUSKESMAS KEPATIHAN GRESIK

RAYA KEPATIHAN 151

7991403

DRG TITIEK SRI HAJATI

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

40

1500000001566

PUSKESMAS KESAMBEN KULON GREIK

KESAMBEN KULON WRINGINANOM GRESIK

60438431

SIDIK NURDIJANTO, SKM

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

41

1500000001566

PUSKESMAS KESAMBEN KULON GREIK

KESAMBEN KULON WRINGINANOM GRESIK

60438431

SIDIK NURDIJANTO, SKM

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

42

1500000001617

PUSKESMAS MANYAR GRESIK

JL RAYA MANYAR 1 GRESIK

DRG JON SUDIRO

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

43

1500000001617

PUSKESMAS MANYAR GRESIK

JL RAYA MANYAR 1 GRESIK

DRG JON SUDIRO

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

44

1500000000756

PUSKESMAS MENGANTI GRESIK

JL RAYA MENGANTI 225 MENGANTI

7911360

DRG TJAHYONO EDY W

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

45

1500000000756

PUSKESMAS MENGANTI GRESIK

JL RAYA MENGANTI 225 MENGANTI

7911360

DRG TJAHYONO EDY W

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

46

1500000001490

PUSKESMAS MENTARAS GRESIK

JL. RAYA MENTARAS DUKUN GRESIK

70954039

DR. RIZAUL FALAH

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

47

1500000001490

PUSKESMAS MENTARAS GRESIK

JL. RAYA MENTARAS DUKUN GRESIK

70954039

DR. RIZAUL FALAH

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

48

1500000001568

PUSKESMAS METATU GRESIK

JL. RAYA METATU 1 GRESIK

7991220

EKO HARIANTO, SKM

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

49

1500000001568

PUSKESMAS METATU GRESIK

JL. RAYA METATU 1 GRESIK

7991220

EKO HARIANTO, SKM

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

50

1500000001564

PUSKESMAS NELAYAN GRESIK

JL. GUB SURYO 33 GRESIK

3983036

DRG PEKIK PITA M

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

51

1500000001564

PUSKESMAS NELAYAN GRESIK

JL. GUB SURYO 33 GRESIK

3983036

DRG PEKIK PITA M

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

52

1500000001488

PUSKESMAS PANCENG GRESIK

JL RAYA PANCENG GRESIK

3940118

DR. JAIMAN

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

53

1500000001488

PUSKESMAS PANCENG GRESIK

JL RAYA PANCENG GRESIK

3940118

DR. JAIMAN

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

54

1500000001560

PUSKESMAS SEKAPUK GRESIK

JK RAYA DS SEKAPUK 15 UJUNG PANGKAH GRESIK

3948128

DR MUJTAHIDAH

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

55

1500000001560

PUSKESMAS SEKAPUK GRESIK

JK RAYA DS SEKAPUK 15 UJUNG PANGKAH GRESIK

3948128

DR MUJTAHIDAH

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

56

1500000001563

PUSKESMAS SEMBAYAT GRESIK

JL. PENDOPO NO 1 SEMBAYAT GRESIK

3949800

DR TITIK ERNA

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

57

1500000001563

PUSKESMAS SEMBAYAT GRESIK

JL. PENDOPO NO 1 SEMBAYAT GRESIK

3949800

DR TITIK ERNA

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

58

1500000001491

PUSKESMAS SIDAYU GRESIK

JL KANJENG PANGERAN 1 GRESIK

3949100

DR WIWIK SUSANTI

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

59

1500000001491

PUSKESMAS SIDAYU GRESIK

JL KANJENG PANGERAN 1 GRESIK

3949100

DR WIWIK SUSANTI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

60

1500000001567

PUSKESMAS SLEMPIT GRESIK

RAYA SLEMPIT KEDAMEAN GRESIK

7911963

DR. SUKADI

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

61

1500000001567

PUSKESMAS SLEMPIT GRESIK

RAYA SLEMPIT KEDAMEAN GRESIK

7911963

DR. SUKADI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

62

1500000000175

PUSKESMAS SUKOMULYO

JL. KALIMANTAN NO.104 GKB GRESIK

3954818

DR LESTARI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

63

1500000000175

PUSKESMAS SUKOMULYO

JL. KALIMANTAN NO.104 GKB GRESIK

3954818

DR LESTARI

PER/05/012015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

64

1500000001562

PUSKESMAS UJUNG PANGKAH GRESIK

JL SITARDA 14 PANGKAH GRESIK

3944760

DR SETYORINI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

65

1500000001562

PUSKESMAS UJUNG PANGKAH GRESIK

JL SITARDA 14 PANGKAH GRESIK

3944760

DR SETYORINI

PER/05/012015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

66

1500000000889

PUSKESMAS WRINGINANOM GRESIK

RAYA WRINGINANOM 111 WRINGINANOM GRESIK

8975330

DR BUDI LUHUR

PER/05/012015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

67

1500000000889

PUSKESMAS WRINGINANOM GRESIK

RAYA WRINGINANOM 111 WRINGINANOM GRESIK

8975330

DR BUDI LUHUR

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

68

1500000000808

RACHMIE CLINIC CERME

JL RAYA GURANGANYAR NO 23 CERME

331284499

DR. RAHMI ZUBAIDAH, SP.MK

PER/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

69

1500000000808

RACHMIE CLINIC CERME

JL RAYA GURANGANYAR NO 23 CERME

331284499

DR. RAHMI ZUBAIDAH, SP.MK

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

70

1500000000807

RACHMIE CLINIC DUDUK SAMPEYAN

RUKO D RAYA REGENCY R1 DUDUK SAMPEYAN GRESIK

331284499

DR RAHMI ZUBAIDAH, SP MK

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

71

1500000000807

RACHMIE CLINIC DUDUK SAMPEYAN

RUKO D RAYA REGENCY R1 DUDUK SAMPEYAN GRESIK

331284499

DR RAHMI ZUBAIDAH, SP MK

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

72

1500000001983

RS FATHMA MEDIKA

JL. PENDOPO 45 SEMBAYAT MANYAR

61111

3943500

DR. ASLUCHUL ALIF

PER/15/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

73

1500000001983

RS FATHMA MEDIKA

JL. PENDOPO 45 SEMBAYAT MANYAR

61111

3943500

DR. ASLUCHUL ALIF

PER/15/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

74

0900000000039

RS PETRO KIMIA GRESIK

JL JEND A YANI 69

3976688

DR.SINGGIH PRIYANTO, MARS

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

75

0900000000039

RS PETRO KIMIA GRESIK

JL JEND A YANI 69

3976688

DR.SINGGIH PRIYANTO, MARS

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

76

7-140944846

RS SURYA MEDIKA

JL LABAN KULON

61111

031397212 1

DR RAMLI TARIGAN

PER/16/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

77

1500000001993

RS SURYA MEDIKA GRESIK

LABAN KULON 58 MENGANTI

61174

7914025

RS RAMLI TARIGAN

PER/16/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

78

1500000001993

RS SURYA MEDIKA GRESIK

LABAN KULON 58 MENGANTI

61174

7914025

RS RAMLI TARIGAN

PER/16/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

79

1500000001519

RS WATES HUSADA

RAYA BALONG PANGGANG GRESIK

DR TITIN

PER/13/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

80

1500000001519

RS WATES HUSADA

RAYA BALONG PANGGANG GRESIK

DR TITIN

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

81

1400000000364

RS.MUHAMMADIYAH GRESIK

JL.KH.KHOLIL NO.88

3981275

DR.MUSA GHUFRON

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

82

1400000000364

RS.MUHAMMADIYAH GRESIK

JL.KH.KHOLIL NO.88

3981275

DR.MUSA GHUFRON

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

83

1400000000363

RSI DARUS SYIFA' BENOWO

JL.RAYA BENOWO NO.5 BENOWO

7406293

DR.HM.FAIZ, SP.THT-KL

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

84

1400000000363

RSI DARUS SYIFA' BENOWO

JL.RAYA BENOWO NO.5 BENOWO

7406293

DR.HM.FAIZ, SP.THT-KL

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

85

0900000000002

RSUD IBNU SINA GRESIK

JL DR WAHIDIN SHD NO 243B

3951239

DR. ENDANG S, SP.THT

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

86

0900000000002

RSUD IBNU SINA GRESIK

JL DR WAHIDIN SHD NO 243B

3951239

DR. ENDANG S, SP.THT

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

87

7-140917243

RUMAS SAKIT FATHMA MEDIKA

JL PENDOPO 45 MANYAR

DR ASLUCHUL

PER/15/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015

MA11222I

61151


SM0480



283 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

88

1500000000809

SURYA GIRI JAYA CERME

JL. RAYA CERME GRESIK

63186435

YUNI HIDAYATI

PER/10/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

89

1500000000809

SURYA GIRI JAYA CERME

JL. RAYA CERME GRESIK

63186435

YUNI HIDAYATI

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

N13- KANTOR CABANG SURABAYA DARMO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001442

BP ASHABUL KAHFI

JL MERBABU BLOK A NO.05 KEPUH PERMAI

8666334

CV KEMBANG TANJUNG

PER/21/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

2

1500000001442

BP ASHABUL KAHFI


8666334

CV KEMBANG TANJUNG

PER/06/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

3

1500000001442

BP ASHABUL KAHFI


8666334

CV KEMBANG TANJUNG

PER/06/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

4

1500000001442

BP ASHABUL KAHFI


8666334

CV KEMBANG TANJUNG

PER/06/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

5

1500000001445

BP HIDAYAH WARU IV

JL GRAHA TIRTA RAYA I NO.28 WARU

70350252

CV KEMBANG TANJUNG

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

6

1500000001445

BP HIDAYAH WARU IV


70350252

CV KEMBANG TANJUNG

PER/07/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

7

1500000001445

BP HIDAYAH WARU IV


70350252

CV KEMBANG TANJUNG

PER/07/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

MA11222I


SM0480



284 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

1500000001445

BP HIDAYAH WARU IV


70350252

CV KEMBANG TANJUNG

PER/07/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

9

1500000001444

BP KEBANGKITAN

JL MANUKAN MADYA 141 SURABAYA

71258886

CV KEMBANG TANJUNG

PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

10

1500000001444

BP KEBANGKITAN


71258886

CV KEMBANG TANJUNG

PER/08/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

11

1500000001444

BP KEBANGKITAN


71258886

CV KEMBANG TANJUNG

PER/08/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

12

1500000001444

BP KEBANGKITAN


71258886

CV KEMBANG TANJUNG

PER/08/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

13

1500000001443

BP KESAYANGAN

JL RUNGKUT ASRI UTARA IV/10 (RL I/H-5) SURABAYA

8700691

CV KEMBANG TANJUNG

PER/09/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

14

1500000001443

BP KESAYANGAN


8700691

CV KEMBANG TANJUNG

PER/09/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

15

1500000001443

BP KESAYANGAN


8700691

CV KEMBANG TANJUNG

PER/20/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

16

1500000001443

BP KESAYANGAN


8700691

CV KEMBANG TANJUNG

PER/09/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

17

1500000001446

BP KESEJAHTERAAN

JL RUNGKUT MAPAN UTARA AA-17 SURABAYA

8706755

CV KEMBANG TANJUNG

PER/10/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

18

1500000001446

BP KESEJAHTERAAN


8706755

CV KEMBANG TANJUNG

PER/19/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

19

1500000001446

BP KESEJAHTERAAN


8706755

CV KEMBANG TANJUNG

PER/10/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

MA11222I


SM0480



285 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

20

1500000001446

BP KESEJAHTERAAN


8706755

CV KEMBANG TANJUNG

PER/10/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

21

1500000001335

KLINIK CITRA MEDICAL CENTRE

JL KETINTANG BARU III/56 SURABAYA

8291214

DR SAID MOHAMMAD T

PER/09/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

22

1500000001335

KLINIK CITRA MEDICAL CENTRE

JL KETINTANG BARU III/56 SURABAYA

8291214

DR SAID MOHAMMAD T

PER/15/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

23

1500000001393

KLINIK KARYA MEDIKA 104

JL BANYU URIP NO 302 SURABAYA

5324326

CV KARYA MEDIKA

PER/16/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

24

1500000001393



5324326

CV KARYA MEDIKA

PER/16/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

25

1500000001393



5324326

CV KARYA MEDIKA

PER/16/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

26

1500000001393



5324326

CV KARYA MEDIKA

PER/16/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

27

1500000001394


BUKIT CITRA DARMO BLOK BC C30/JL KLAKAH REJO I-20 SURABAYA

CV KARYA MEDIKA

PER/17/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

28

1500000001394



CV KARYA MEDIKA

PER/17/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

29

1500000001394



CV KARYA MEDIKA

PER/17/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

30

1500000001394



CV KARYA MEDIKA

PER/17/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

31

1500000001395


JL NGAGLIK NO 47 SURABAYA

CV KARYA MEDIKA

PER/18/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

MA11222I

3764782


SM0480



286 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

32

1500000001395



3764782

CV KARYA MEDIKA

PER/15/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

33

1500000001395



3764782

CV KARYA MEDIKA

PER/18/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

34

1500000001395



3764782

CV KARYA MEDIKA

PER/18/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

35

1500000001379

KLINIK SARTIKA 36

BRATANG BINANGUN GANG VI/47 SURABAYA

34417343

DR LILIK SRI HARTINI

PER/11/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

36

1500000001379

KLINIK SARTIKA 36


34417343


PER/11/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

37

1500000001379

KLINIK SARTIKA 36


34417343


PER/11/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

38

1500000001379

KLINIK SARTIKA 36


34417343


PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

39

1500000001377

KLINIK SARTIKA 44

JL RAYA MASTRIP NO 32 KARANG PILANG SURABAYA

34200705


PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

40

1500000001377

KLINIK SARTIKA 44


34200705


PER/12/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

41

1500000001377

KLINIK SARTIKA 44


34200705


PER/12/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

42

1500000001377

KLINIK SARTIKA 44


34200705


PER/12/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

43

1500000001376

KLINIK SARTIKA 59

JL MANUKAN TENGAH 9K/10 SURABAYA

34183507


PER/12/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

MA11222I


SM0480



287 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

44

1500000001376

KLINIK SARTIKA 59

JL MANUKAN TENGAH 9K/10 SURABAYA

34183507


PER/13/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

45

1500000001317

KLINIK SARTIKA 77

JL TRUNOJOYO NO 2 SEPANJANG

7871549


PER/08/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

46

1500000001317

KLINIK SARTIKA 77

JL TRUNOJOYO NO 2 SEPANJANG

7871549


PER/14/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

47

N13

POLI SARTIKA 36


5017791


PER/08/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

48

1500000001373

POLIKLINIK PUTRI RAHAYU

JL MASTRIP IX/9 WARUGUNUNG KARANGPILANG

7667983

BILAL ZAENAL ABIDIN

PER/13/062015

RS.TRAUMA CENTRE

01/06/2015

31/12/2015

49

1500000001373



7667983

BILAL ZAENAL ABIDIN

PER/05/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

50

1500000001373



7667983

BILAL ZAENAL ABIDIN

PER/05/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

51

1500000001373



7667983

BILAL ZAENAL ABIDIN

PER/05/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

52

1100000000018

RS BHAKTI RAHAYU (TC)

JL KETINTANG MADYA I / 6 SURABAYA

8289668

PT BHAKTI RAHAYU

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

53

1100000000018

RS BHAKTI RAHAYU (TC)

JL KETINTANG MADYA I / 6 SURABAYA

8289668

PT BHAKTI RAHAYU

PER/03/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

54

1100000000008

RS BUNDA SURABAYA

JL RAYA KANDANGAN 23-24

7440077


PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

55

1100000000008

RS BUNDA SURABAYA

JL RAYA KANDANGAN 23-24

7440077


PER/02/012015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I


SM0480



288 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

56

0900000000003

RS MUJI RAHAYU

JL RY MANUKAN WETAN 68-68A SURABAYA

7404132

YAYASAN MUJI RAHAYU

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

57

0900000000003

RS MUJI RAHAYU

JL RY MANUKAN WETAN 68-68A SURABAYA

7404132

YAYASAN MUJI RAHAYU

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

58

1100000000019

RS WIJAYA (TC)

JL RAYA MENGANTI WIYUNG NO 398 SURABAYA

7523087

YAYASAN WIJAYA

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

59

1400000000385

RS WIYUNG SEJAHTERA

JL KARANGAN PDAM NO 1-3 WIYUNG SURABAYA

7532653

PT WIYUNG SEJAHTERA

PER/04/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

N14- KANTOR CABANG SURABAYA TANJUNG PERAK

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

1

1500000000728

BP KLINIK INDO SEHAT 2003

JL. WONOSARI LOR 99-101 (RUKO AMIRA GRAHA BLOK A/2) SURABAYA

3761150

2

1500000000953

BP PERDANA HUSADA

MANUKAN KRAJAN 32Q/2

7403300

3

1500000001612

BP RAJAWALI 1

JL KREMBANGAN BARAT NO 26 D

34061757

4

1500000001610

BP SURYA GIRI JAYA

JL KENJERAN NO 189

31362696

5

1500000000887

DINAYLA UTAMA 105

RAYA BIBIS NO.36

MA11222I

PIMPINAN TIPE IKS

AWAL IKS

AKHIR IKS

PER/07/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/12/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DR RR KARTIWI ATMINI

PER/017/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

DR RISTA YULIANA SUGIANTO

PER/015/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/11/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

HASAN BASRI


SM0480



289 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6

1500000000891

DINAYLA UTAMA 79

SIMOREJO SARI B/54

7496347

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

30/06/2016

7

1500000000888

DINAYLA UTAMA 84

SIMOPOMAHAN 3/14

3136269

PER/10/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

8

1500000001065

KLINIK MITRA SEHAT

JL.RAYA MENGANTI NO.411

PER/13/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

9

1500000001554

KLINIK NURANI JAYA 121

JL PUTRO AGUNG WETAN NO 58

331212060

PER/016/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000000737

KLINIK PALANG MERAH INDONESIA

JL. TAMBAKSARI NO. 49 SURABAYA

5032103

PER/06/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1400000000517

KLINIK WISMA HUSADA

JL DUKUH SETRO 7A KAV NO 2

PER/ 01/ 012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

12

1400000000517

KLINIK WISMA HUSADA


PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

13

1400000000517

KLINIK WISMA HUSADA


PER/ 01/ 01-2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

14

1400000000517

KLINIK WISMA HUSADA


PER/ 02/ 012015

FFS

02/01/2015

31/12/2015

15

0700000000012

RS AL-IRSYAD

JL KHM MANSUR 210-214 SURABAYA

3531223

DR AHMAD BAKARMAN, MARS

PER/ 02/012016

RS.TRAUMA CENTRE

13/01/2016

31/10/2016

16

0700000000012

RS AL-IRSYAD

JL KHM MANSUR 210-214 SURABAYA

3531223

DR AHMAD BAKARMAN, MARS

PER/ 02/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

17

1500000000726

RS BHAYANGKARA TK. IV M. DAHLAN

JL. SRITI NO. 02 SURABAYA

3551043

DR. SIGIT LESMONOJATI

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I

H. IR. TRI SISWANTO. MM


SM0480



290 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

18

1400000000469

RUMAH SAKIT PRIMASATYA HUSADA CITRA

JL. PRAPAT KURUNG SELATAN NO. 1

3294801

PT RUMAH SAKIT PRIMASATYA HUSADA CITRA

PER/ 03/ 012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

19

1400000000469

RUMAH SAKIT PRIMASATYA HUSADA CITRA

JL. PRAPAT KURUNG SELATAN NO. 1

3294801

PT RUMAH SAKIT PRIMASATYA HUSADA CITRA

PER/ 01/ 012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

N15- KANTOR CABANG SURABAYA RUNGKUT

NAMA PROVIDER

ALAMAT

1

1500000001024

KLINIK DINAYLA UTAMA 81

JL. RAYA MARGOREJO NO 8 WONOCOLO SURABAYA

2

1348

KLINIK DOKTER AYOMAN KELUARGA

JL SUTOREJO PRIMA UTARA PDD_1

3

1100000000011

KLINIK MEDICO SIER

RUKO GALAXY SIER, JL. RUNGKUT INDUSTRI III NO. 7-G SURABAYA

4

1100000000011

KLINIK MEDICO SIER

RUKO GALAXY SIER, JL. RUNGKUT INDUSTRI III NO. 7-G SURABAYA

5

1347


6

1347

7

1346

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8419906

SITI MURIYAH

PER/01/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

5954477

NIKEN MADIANINGRUM

1346

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

60293

70932808

PT PRIMA KARYA BERSAUDARA

PER/01/092015

RS.TRAUMA CENTRE

21/12/2015

31/12/2015

60293

70932808

PT PRIMA KARYA BERSAUDARA

PER/01/092015

RS.TRAUMA CENTRE

28/12/2015

31/12/2016

JL KENDANGSARI GG III NO 20

8483147

NURANI JAYA

1347

RS.TRAUMA CENTRE

01/06/2015

31/05/2016


JL KENDANGSARI GG III NO 20

8483147

NURANI JAYA

1347

RS.TRAUMA CENTRE

01/06/2015

31/05/2016


JL KUTISARI SELATAN NO 4 SURABAYA

8473668

KLINIK NURANI

1346

RS.TRAUMA CENTRE

01/06/2015

01/05/2016

60236


SM0480



291 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

1400000000361

KLINIK SIER SEJAHTERA

JL. RUNGKUT INDUSTRI RAYA NO. 10A

60298

71384589

CV. BANGUN SEJAHTERA

PER/01/102015

RS.TRAUMA CENTRE

28/12/2015

31/12/2016

9

1400000000361

KLINIK SIER SEJAHTERA

JL. RUNGKUT INDUSTRI RAYA NO. 10A

60298

71384589

CV. BANGUN SEJAHTERA

PER/01/10/2015

RS.TRAUMA CENTRE

21/12/2015

31/12/2015

10

7-804633213

RS ISLAM JEMURSARI SURABAYA

JL. JEMURSARI NO. 51-57

60236

PROF. DR. DR. ROCHMAD ROMDONI, SP.PD.,SP.JP(K)

PER/01/082015

RS.TRAUMA CENTRE

03/12/2015

31/12/2016

11

1400000000362

RS ISLAM SURABAYA A YANI

JL. AHMAD YANI NO. 2 - 4 WONOKROMO

60241

8284505

YAYASAN RUMAH SAKIT ISLAM SURABAYA

PER/01/112015

RS.TRAUMA CENTRE

28/12/2015

31/12/2016

12

1400000000362

RS ISLAM SURABAYA A YANI

JL. AHMAD YANI NO. 2 - 4 WONOKROMO

60241

8284505

YAYASAN RUMAH SAKIT ISLAM SURABAYA

PER/01/112015

RS.TRAUMA CENTRE

21/12/2015

31/12/2015

13

1100000000022

RS ISLAM SURABAYA JEMURSARI

JL JEMURSARI 51-57

60236

847187778

YAYASAN RS ISLAM SURABAYA

PER/01/082015

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

14

1500000001994

RS. ROYAL SURABAYA

JL. RUNGKUT INDUSTRI I/1

60111

8476111

PT. PRIMA KARYA HUSADA SURABAYA

PER/01/102015

RS.TRAUMA CENTRE

28/10/2015

27/10/2016

KANTOR CABANG

NO

KODE PROVIDER

:

P00- KANTOR CABANG PONTIANAK

NAMA PROVIDER

ALAMAT

1

1500000001639

RSUD DR. ABDUL AZIZ SINGKAWANG

JL. DR. SOETOMO SINGKAWANG KALBAR

2

1500000001640

RSUD PEMANGKAT

JL A KADIR KASIM NO. 20 PEMANGKAT

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

631798 DR SEMUEL GERITS RAHANRA, MPH

TIPE IKS

AWAL IKS

AKHIR IKS

PER/04/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PER/03/03/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016


SM0480



292 / 322 09-02-2016 18:49:59


NO

:

KODE PROVIDER

R00- KANTOR CABANG BANJARMASIN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

1

1400000000227

BLUD RUMAH SAKIT HADJI BOEJASIN

JL H BOEJASIN NO 68 PELAIHARI

22009

2

1500000000151

RS KHUSUS BEDAH BANJARMASIN SIAGA

JL JEND AHMAD YANI KM 4.5 NO 73

3267352

3

1500000000216

RSUD ANSARI SALEH

JL. BRIGJEND H. HASAN BASRI NO 1

4

1500000000949

RSUD BRIGJEND H HASAN BASRY KANDANGAN

5

1500000000950

6

TIPE IKS

AWAL IKS

AKHIR IKS

PER/05/042015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

PER/02/022015

RS.TRAUMA CENTRE

02/02/2015

29/02/2016

6710000

PER/03/022015

RS.TRAUMA CENTRE

03/02/2015

31/01/2016

JL JEND SUDIRMAN NO 29 KANDANGAN

21653

PER/09/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

RSUD DATU SANGGUL RANTAU

JL. BRIGJEND H HASAN BASRY KM 1 RANTAU

31075

PER/10/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1500000000020

RSUD H ABDUL AZIZ MARABAHAN

JL JEND. SUDIRMAN NO 10 RT 13 RW 01 MARABAHAN

4799118

PER/15/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

7

1500000000765

RUMAH SAKIT BHAYANGKARA BANJARMASIN

JL. A. YANI KM 3,5 BANJARMASIN

3256528

PER/07/052015

RS.TRAUMA CENTRE

06/05/2015

31/05/2017

8

1500000001493

RUMAH SAKIT SARI MULIA BANJARMASIN

JL PANGERAN ANTASARI NO 139 BANJARMASIN

3252570

PER/08/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1400000000226

RUMAH SAKIT SUAKA INSAN BANJARMASIN

JL H ZAFRI ZAMZAM NO 60 BANJARMASIN

3353335

PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

KANTOR CABANG

MA11222I

:

PT SUTIKSNA

YAYASAN SUAKA INSAN

R01- KANTOR CABANG SAMPIT


SM0480



293 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001648

PUSKESMAS BAAMANG I

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

2

1500000001650

PUSKESMAS BAAMANG II

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

3

1500000001643

PUSKESMAS BAGENDANG

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

4

1500000001634

PUSKESMAS BAPINANG

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

5

1500000001657

PUSKESMAS CEMPAKA MULIA

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

6

1500000001645

PUSKESMAS KETAPANG I

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

7

1500000001646

PUSKESMAS KETAPANG II

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

8

1500000001656

PUSKESMAS KOTA BESI

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

9

1500000001661

PUSKESMAS KUALA KUAYAN

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

10

1500000001654

PUSKESMAS MENTAYA SEBERANG

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

11

1500000001659

PUSKESMAS PARENGGEAN I

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

12

1500000001660

PUSKESMAS PARENGGEAN II

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I


SM0480



294 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1500000001653

PUSKESMAS PASIR PUTIH

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

14

1500000001658

PUSKESMAS PUNDU

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

15

1500000001642

PUSKESMAS SAMUDA

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

16

1500000001655

PUSKESMAS SEBABI

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

17

1500000001663

PUSKESMAS TUMBANG KALANG

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

18

1500000001664

PUSKESMAS TUMBANG PENYAHUAN

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

19

1500000001662

PUSKESMAS TUMBANG SANGAI

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

20

1500000001635

PUSKESMAS UJUNG PANDARAN

PER/02/062015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

21

1400000000145

RSUD DR MURJANI SAMPIT

JL HM ARSYAD NO 65

25052

PEMKAB KOTIM

PER/05/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1400000000146

RSUD KUALA PEMBUANG

JL. A. YANI NO.30 KUALA PEMBUANG

21017

RSUD KUALA PEMBUANG

PER/06/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

23

1500000000116

RUMAH SAKIT DAERAH HANAU

JL SAMPIT-PANGKALANBUN KM 142 PEMBUANG HULU

2033125

PER/04/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KANTOR CABANG

MA11222I

:

R02- KANTOR CABANG KOTABARU


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295 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

1

1400000000374

RSUD H ABDURRAHMAN NOOR TANAH BUMBU

KOMP PERKANTORAN TANAH BUMBU

71067

2

1500000000845

RUMAH SAKIT UMUM DAERAH KOTABARU

JL.H.HASAN BASRI NO.57

3

1500000000845

RUMAH SAKIT UMUM DAERAH KOTABARU

JL.H.HASAN BASRI NO.57

KANTOR CABANG

NO

KODE PROVIDER

:

PIMPINAN TIPE IKS

AWAL IKS

AKHIR IKS

PER/02/032015

RS.TRAUMA CENTRE

01/04/2015

28/02/2016

22945

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22945

PER/04/052015

RS.TRAUMA CENTRE

01/05/2015

31/12/2015

PEMKAB TANAH BUMBU

R03- KANTOR CABANG PALANGKARAYA

NAMA PROVIDER

ALAMAT

1

1500000001713

BLK DINAS SOSIAL DAN TENAGA KERJA KOTA PALANGKARAYA

JL TJILIK RIWUT KM 6.5

2

1400000000279

BLUD RUMAH SAKIT UMUM DAERAH KUALA KURUN

JL A YANI NO 43 KUALA KURUN

3

1500000000632

KLINIK INSANI MUARA TEWEH

4

1500000000740

5

6

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DINAS SOSIAL DAN TENAGA KERJA KOTA PALANGKARAYA

PER/11/05/2015

RS.TRAUMA CENTRE

11/05/2015

11/06/2016

31459

DAERAH KUALA KURUN

PER/18/082015

RS.TRAUMA CENTRE

01/08/2015

01/08/2016

JL.JEND.SUDIRMAN NO.09 RT.28 MUARA TEWEH

49418222

HERIANSYAH

PER/015/042015

RS.TRAUMA CENTRE

07/04/2015

07/04/2017

RS. PKU MUHAMMADIYAH PALANGKARAYA

JL.RTA. MILONO KM.2.5

3239444

DR.SUYANTO, SP.PD

PER/06/042015

RS.TRAUMA CENTRE

22/04/2015

22/05/2017

1400000000137

RSUD JARAGA SASAMEH

JL PATIANON NO 6 BUNTOK

21021

RSUD BUNTOK

PER/07/042015

RS.TRAUMA CENTRE

30/04/2015

27/04/2017

1500000001397

RSUD. PURUK CAHU

JL. A. YANI NO.497 PURUK CAHU

31300

PER/14/062015

RS.TRAUMA CENTRE

11/06/2015

11/06/2017

MA11222I


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296 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

7

1500000001396

RSUD. TAMIANG LAYANG

JL.NANSARUNAI TAMIANG LAYANG NO.62

8

1500000001375

RUMAH SAKIT TK IV. 12.07.03 PALANGKA (RUMKIT TNI AD)

JL DIPONEGEORO NO 55 PALANGKA RAYA

KANTOR CABANG

NO

:

KODE PROVIDER

KODE POS

IKS TELEPON

PIMPINAN NO IKS

2091235

TIPE IKS

AWAL IKS

AKHIR IKS

ANDA KRISELINA MKES

PER/17/062015

RS.TRAUMA CENTRE

11/06/2015

11/07/2017

DR. I NYOMAN INDRAWAN SO.PD

PER/12/052015

RS.TRAUMA CENTRE

25/05/2015

25/05/2017

R04- KANTOR CABANG PANGKALAN BUN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-1706946523

PUSKESMAS KUMAI

JL PEMUDA KECAMATAN KUMAI

74181

DR ABIMAYU

PER/03/012016

RS.TRAUMA CENTRE

29/01/2016

18/01/2017

2

7-1702557673

PUSKESMAS SEMANGGANG

JL A YANI KM 60 SEMANGGANG KEC PANGKALAN BANTENG

74183

DR JHONFERI SIDABALOK

PER/02/012016

RS.TRAUMA CENTRE

29/01/2016

18/01/2017

3

1400000000346

RSUD IMANUDDIN PANGKALAN BUN

JLN SUTAN SYAHRIR PANGKALAN BUN

PER/03/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

KANTOR CABANG

NO

KODE PROVIDER

:

S00- KANTOR CABANG BALIKPAPAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000552

POLIKLINIK IBNU SINA BALIKPAPAN

JL.JEND.A.YANI NO.252 KEL.MUARA RAPAK

7091900

DR.HADI YUNIARKO

PER/16/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

2

1500000001318

PT.MITRA SEHAT UTAMA (KLINIK MITRA SEHAT)

JL.SOEKARO HATTA NO.01 RT.82 KEL.BATU AMPAR KEC.BALIKPAPAN UTARA

441362

DEBBY TANDY, SE

PER/19/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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297 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

AWAL IKS

AKHIR IKS

PER/02/092015

RS.TRAUMA CENTRE

21/12/2015

07/09/2016

JL. AL-FALAH RT.33 NO.02, KEC. BALIKPAPAN BARAT

PER/43/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PUSKESMAS BARU TENGAH

JL. LETJEN SOEPRAPTO RT.26 NO.30, KEC. BALIKPAPAN BARAT

PER/46/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1500000001427

PUSKESMAS BARU ULU

JL. WOLTER MONGINSIDI RT.47 NO.85, KEC. BALIKPAPAN BARAT

PER/41/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

7

1500000001437

PUSKESMAS BATU AMPAR

JL. A.WAHAB SYACHRANI RT.10, KEC. BALIKPAPAN UTARA

PER/31/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

8

1500000001440

PUSKESMAS DAMAI

JL. MT HARYONO, KEC. BALIKPAPAN SELATAN

PER/22/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

9

1500000001450

PUSKESMAS GUNUNG BAHAGIA

JL. RUHUI RAHAYU RT.15 NO.47, KEC. BALIKPAPAN SELATAN

PER/25/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1500000001435

PUSKESMAS GUNUNG SAMARINDA

JL. INDRAKILA RT.22, KEC. BALIKPAPAN UTARA

PER/33/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

1500000001431

PUSKESMAS GUNUNG SARI ILIR

JL. MEKAR SARI, KEC. BALIKPAPAN TENGAH

PER/37/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

12

1500000001428

PUSKESMAS GUNUNG SARI ULU

DS. GUNUNGSARI ULU KEC. BALIKPAPAN TENGAH

PER/40/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

13

1500000001432

PUSKESMAS KARANG JATI

JL. SULTAN ALAUDDIN RT.01 NO.39, KEC. BALIKPAPAN TENGAH

PER/36/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

14

1500000001436

PUSKESMAS KARANG JOANG

JL. SOEKARNO HATTA RT.21 KM.12,5, KEC. BALIKPAPAN UTARA

PER/32/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

3

7-1030679543

PUKESMAS BATU KAJANG

JL.NEGARA RT.09 KE.BATU SOPANG

4

1500000001423

PUSKESMAS BARU ILIR

5

1500000001421

6

MA11222I

76252

I DEWA MADE SUDARSANA

TIPE IKS


SM0480



298 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

15

1500000001430

PUSKESMAS KARANG REJO

KEL. KARANG REJO, KEC. BALIKPAPAN TENGAH

PER/38/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1500000001426

PUSKESMAS KARIANGAU

JL. HASANUDDIN NO.118, KEC. BALIKPAPAN BARAT

PER/42/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

17

7-1039247964

PUSKESMAS KAYUNGO

JL.ALAS DS.LONG GELANG , KEC. LONG IKIS

76282


PER/15/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

18

7-1036615116

PUSKESMAS KERANG

JL.HAUR KUNING DS.KERANG , KEC. BATU ENGAU

76261


PER/04/092015

RS.TRAUMA CENTRE

23/12/2015

07/09/2016

19

1500000001447

PUSKESMAS KLANDASAN ILIR

JL. JEND. SUDIRMAN NO.118, KEC. BALIKPAPAN SELATAN

PER/23/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

20

7-1039186643

PUSKESMAS KRAYAN

DS.KRAYAN SENTOSA , KEC.LONG IKIS

76282


PER/14/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

21

7-1038939360

PUSKESMAS KUARO

JL.JEND.A.YANI RT.018 RW.005 KEL.KUARO , KEC. KUARO

76281


PER/11/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

22

1500000001441

PUSKESMAS LAMARU

JL. PUSKESMAS, LAMARU, KEC. BALIKPAPAN TIMUR

PER/28/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

23

7-1039031521

PUSKESMAS LOLO

JL.SAWIT DS.KALUANG LOLO, KEC.KUARO

76281


PER/12/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

24

7-1039093892

PUSKESMAS LONG IKIS

JL.NEGARA KM.82 , KEC.LONG IKIS

76282


PER/13/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

25

7-1039387686

PUSKESMAS LONG KALI

JL.PROPINSI KM 63 KADEMAN , KEC.LONG KALI

76283


PER/17/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

26

1500000001451

PUSKESMAS MANGGAR

JL. MULAWARMAN RT.07, KEC. BALIKPAPAN TIMUR

PER/27/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


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299 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

27

1500000001438

PUSKESMAS MANGGAR BARU

JL. PJHI RT.21, KEC. BALIKPAPAN TIMUR

PER/30/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

28

1500000001420

PUSKESMAS MARGASARI

JL. PANDAN BARAT RT.15 NO.26, KEC. BALIKPAPAN BARAT

PER/47/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

29

1500000001422

PUSKESMAS MARGO MULYO

JL. GUNUNG IV RT.45 NO.9, KEC. BALIKPAPAN BARAT

PER/45/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

30

1500000001433

PUSKESMAS MEKAR SARI

JL. POLOKLINIK, KEC. BALIKPAPAN TENGAH

PER/35/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

31

7-1039510453

PUSKESMAS MENDIK

RT.1 DS.MENDIK , KEC.LONG KALI

76283


PER/18/092015

RS.TRAUMA CENTRE

17/12/2015

07/09/2016

32

7-1039309985

PUSKESMAS MUARA KOMAM

JL.NEGARA KM 171 NO.40 RT.06 KEL.MUARA KOMAM KEC.MUARA KOMAM

76253


PER/16/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

33

1500000001434

PUSKESMAS MUARA RAPAK

JL. INPRES III RT.24 NO.124A, KEC. BALIKPAPAN UTARA

PER/34/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

34

7-1035423185

PUSKESMAS MUSER

JL.ANWAR NO.43 RT.04 DS.MUSER ,KEC.MUARA SEMU

76252


PER/03/092015

RS.TRAUMA CENTRE

23/12/2015

07/09/2016

35

7-1038167538

PUSKESMAS PADANG PENGRAPAT

JL.GAJAH MADA DS.PADANG PENGRAPAT , KEC.TANAH GROGOT

76251


PER/09/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016

36

7-1037831466

PUSKESMAS PASIR BELENGKONG

JL.NEGARA DS. PASER BELENGKONG KEC.PASER BELENGKONG

76271


PER/07/09/2015

RS.TRAUMA CENTRE

21/12/2015

07/09/2016

37

1500000001448

PUSKESMAS PRAPATAN

JL. GUNUNG PASIR NO.1, KEC. BALIKPAPAN SELATAN

PER/24/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

38

1500000001424

PUSKESMAS SEPINGGAN

JL. MARSMA ISWAHYUDI NO.456, KEC. BALIKPAPAN SELATAN

PER/21/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

MA11222I


SM0480



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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

39

1500000001425

PUSKESMAS SIDOMULYO

JL. SIDOMULYO RT.2 NO.56, KEC. BALIKPAPAN BARAT

40

7-1037429485

PUSKESMAS SUATANG BARU

JL.NEGARA NO.02 DS.SUATANG BARU , KEC.PASER BELENGKONG

76271

41

7-1037954297

PUSKESMAS SULILIRAN BARU

JL.NUSA INDAH RT.22DS.SULILIRAN BARU KEC.PASER BELENGKONG

76271

42

1500000001429

PUSKESMAS SUMBER REJO

JL. BINA RAGA RT.31 NO.73, KEC. BALIKPAPAN TENGAH

43

7-1038866109

PUSKESMAS TANAH GROGOT

JL.PANGLIMA SENTIK DS, TANAH GROGOT , KEC.TANAH GROGOT

76251

44

7-1036975507

PUSKESMAS TANJUNG ARU

JL.M.DAHRI RT.04 NO.49 DS.TANJUNG KEC.TANJUNG HARAPAN

76261

45

1500000001449

PUSKESMAS TELAGA SARI

46

1500000001439

47

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/44/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016


PER/06/092015

RS.TRAUMA CENTRE

21/12/2015

07/09/2016


PER/08/092015

RS.TRAUMA CENTRE

21/12/2015

07/09/2016

PER/39/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016


PER/10/092015

RS.TRAUMA CENTRE

18/12/2015

07/09/2016


PER/05/092015

RS.TRAUMA CENTRE

21/12/2015

07/09/2016

JL. PRAPATAN DALAM NO.1, KEC. BALIKPAPAN SELATAN

PER/26/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PUSKESMAS TERITIP

JL. PENDIDIKAN RT.18, KEC. BALIKPAPAN TIMUR

PER/29/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

1400000000064

RS BALIKPAPAN BARU

JL MT HARYONO KOMPLEK BALIKPAPAN BARU BLOK A3 A NO 7-9 KALTIM

877330

DR M DANARTO, M MED

PER/04/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

48

1400000000045

RS PERTAMINA BALIKPAPAN

JL JEND SUDIRMAN NO I BALIKPAPAN

734020

PT PERTAMINA BINA MEDIKA

PER/02/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

49

1400000000065

RS RESTU IBU BALIKPAPAN

JL JEND A YANI NO 12 BALIKPAPAN

427342

PT RESTU IBU BALIKPAPAN

PER/03/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

50

1500000000729

RSUD KOTA BALIKPAPAN

JL.MAYJEND SUTOYO RT.01 KEL.GUNUNG SARI ULU KEC.BALIKPAPAN TENGAH

DRG.DYAH MURYANI

PER/15/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I


SM0480



301 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

51

1500000000184

RSUD PENAJAM PASER UTARA

JL.PROPINSI KM.09 PENAJAM PASER UTARA KALTIM

7211361

DR.JANSJE GRACE MAKISURAT

PER/10/012015

RS.TRAUMA CENTRE

05/02/2015

05/02/2016

52

1500000000188

RUMAH SAKIT BHAYANGKARA BALIKPAPAN

JL.JEND.SUDIRMAN NO.14 BALIKPAPAN

421261

DR.WILDAN DJAYA SOEKMARA,SP.B,FINACS

PER/06/012015

RS.TRAUMA CENTRE

01/02/2015

28/02/2016

53

1500000001325

RUMAH SAKIT TINGKAT IV LANUD BALIKPAPAN

JL.MARSMA ISWAHYUDI RT.31 KEL.SEPINGGAN BARU KEC.BALIKPAPAN SELATAN

761141

DR.MARKUS KABAN, SP.PK

PER/18/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

54

1400000000047

RUMAH SAKIT UMUM DAERAH PANGLIMA SEBAYA

JL KESUMA BANGSA KM 5 TANA PASER

24563

PER/05/022015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

55

1300000000048

SILOAM HOSPITALS

JL MT. HARYONO NO. 9 BALIKPAPAN

7206509

PER/38/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

56

1500000001034

UPTD BALAI LATIHAN KERJA INDUSTRI BALIKPAPAN

JL.SEPINGGAN BARU NO.31 BALIKPAPAN

762681

PER/01/012015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

KANTOR CABANG

NO

KODE PROVIDER

:

S01- KANTOR CABANG SAMARINDA

NAMA PROVIDER

ALAMAT

1

1500000001816

BALAI LATIHAN KERJA INDUSTRI SAMARINDA

JALAN UNTUNG SUROPATI NO.43, SUNGAI KUNJANG, KOTA SAMARINDA, KALIMANTAN TIMU

2

1500000000915

KLINIK SANTO YOSEF

JL OLAH BEBAYA RT 10 LINGGANG BIGUNG

3

7-1380214421

PUKESMAS BANTUAS

JL BANTUAS PALARAN

MA11222I

PT BALIKPAPAN DAMAI HUSADA

KODE POS

75126

75241

IKS TELEPON

PIMPINAN NO IKS

272421

PEMERINTAH

TIPE IKS

AWAL IKS

AKHIR IKS

PER/04/062015

RS.TRAUMA CENTRE

04/06/2015

04/06/2016

021/K.ST.Y/IV/2 015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016


SM0480



302 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

7-1464240699

PUSKESMAS AIR PUTIH

JL AIR PUTIH SAMARINDA ULU

75122

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

7-1464311570

PUSKESMAS BAQA

JL BAQA SAMARINDA SEBERANG

75131

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

6

7-1356917662

PUSKESMAS BENGKURING

BENGKURING

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

7

7-1380408843

PUSKESMAS BUKUAN

JL BUKUAN PALARAN

75241

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

8

7-1464600433

PUSKESMAS HARAPAN BARU

JL HARAPAN BARU SAMARINDA SEBERANG

75131

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

9

7-1359826423

PUSKESMAS JUANDA

JL IR JUANDA SAMARINDA ULU

75122

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

10

7-1507208803

PUSKESMAS KARANG ASAM SAMARINDA

JL KARANG ASAM

75125

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

11

7-1464440551

PUSKESMAS LEMPAKE

JL LEMPAKE SAMARINDA UTARA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

12

7-1466746238

PUSKESMAS LOA BAKUNG

JL LOA BAKUNG SUNGAI KUNJANG

75125

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

13

7-1380502014

PUSKESMAS MAKROMAN

JL MAKROMAN PALARAN

75241

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

14

7-1464657234

PUSKESMAS MANGKUPALAS

JL MANGKUPALAS SAMARINDA SEBERANG

75131

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

15

7-1464111057

PUSKESMAS PALARAN

JL PALARAN

75241

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

MA11222I


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

7-1380304232

PUSKESMAS PASUNDAN

JL PASUNDAN KEL JAWA SAMARINDA ULU

75122

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

17

7-1463967676

PUSKESMAS REMAJA

JL REMAJA SUNGAI PINANG

75117

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

18

7-1464167298

PUSKESMAS SAMBUTAN

JL SAMBUTAN

75114

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

19

7-1461318105

PUSKESMAS SEGIRI

JL SEGIRI SAMARINDA KOT

75111

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

20

7-1380543865

PUSKESMAS SEMPAJA

SEMPAJA SAMARINDA UTARA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

21

7-1465607297

PUSKESMAS SIDOMULYO

JL SIDOMULYO SAMARINDA ILIR

75114

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

22

7-1464546252

PUSKESMAS SUNGAI KAPIH

JL SUNGAI KAPIH SAMBUTAN

75114

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

23

7-1378835889

PUSKESMAS SUNGAI SIRING

KELURAHAN SUNGAI SIRING SAMARINDA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

24

7-1380635626

PUSKESMAS TEMINDUNG

JL TEMINDUNG SAMARINDA UTARA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

25

1500000000941

PUSKESMAS TRAUMA CENTRE

JL CIPTO MANGUNKUSUMO KEL SENGKOTEK KEC LOA JANAN ILIR

PKS/01/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

26

7-1380777307

PUSKESMAS WONOREJO

KELURAHAN WONOREJO

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

27

1500000001242

RS SAMARINDA MEDIKA CITRA

JL KADRIE OENING NO 81 RT 35 AIR HITAM

PKS/02/04/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

MA11222I

75125

PEMERINTAH


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

28

1500000000320

RSUD ABDUL WAHAB SJAHRANI

JL PMI KOTA SAMARINDA

29

7-1356184197

RSUD I.A MOEIS

JL H.A M.M RIFADDIN

KANTOR CABANG

NO

:

KODE PROVIDER

KODE POS

IKS TELEPON

PIMPINAN NO IKS

75131

PEMERINTAH

TIPE IKS

AWAL IKS

AKHIR IKS

PKS/01/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

PKS/01/12.2015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

S02- KANTOR CABANG TARAKAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000595

KLINIK CARSA

JL. SEBENGKOK TIRAM NO. 3

31457

SITTI RUJIAH, AMD.KEB

PER/09/042015

RS.TRAUMA CENTRE

21/04/2015

20/04/2016

2

1500000001245

RS PERTAMEDIKA TARAKAN

JL. MULAWARMAN NO. 14

31403

RS PERTAMEDIKA TARAKAN

PER/11/052015

RS.TRAUMA CENTRE

06/05/2015

05/05/2016

3

1500000000257

RSD DR. H. SOEMARNO SOSROADMODJO

TANJUNG SELOR

PEMKAB BULUNGAN

PER/04/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

4

1100000000038

RSUD NUNUKAN TC

JLN. SEI FATIMAH

PEMKAB NUNUKAN

PER/14/082015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

5

7-582361147

RSUD TARAKAN S02 TC

JL P IRIAN NO 1 TARAKAN

PEMPROV KALTIM

PER/13/082015

RS.TRAUMA CENTRE

30/11/2015

02/08/2016

6

1100000000037

RSUD TARAKAN TC

JL.P.IRIAN SKIP

PEMPROV KALTIM

0PER/12/07/2015

RS.TRAUMA CENTRE

01/08/2015

31/12/2015

KANTOR CABANG

MA11222I

:

24416

00000

21166

S03- KANTOR CABANG BONTANG


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PT KALTIM MEDIKA UTAMA

PER/12/052015

RS.TRAUMA CENTRE

27/04/2015

26/04/2017


PER/13/052015

RS.TRAUMA CENTRE

27/04/2015

26/04/2017

23388


PER/14/052015

RS.TRAUMA CENTRE

27/04/2015

26/04/2017

JL.YOS SUDARSO I NO.01SANGATTA

24555

RUSTAM EFFENDI

PER/16/082015

RS.TRAUMA CENTRE

28/08/2015

27/08/2016

RS. PUPUK KALTIM BONTANG

JL OKSIGEN NO 1

41118


PER/08/042015

RS.TRAUMA CENTRE

20/04/2015

19/04/2017

1400000000234

RSUD TAMAN HUSADA BONTANG

JL. LETJEND S. PARMAN NO. 01

3036990

PER/09/042015

RS.TRAUMA CENTRE

24/04/2015

23/04/2016

1500000000932

RSUD. KUDUNGGA KAB KUTAI TIMUR

JL. SUKARNO HATTA SANGATTA

PER/10/042015

RS.TRAUMA CENTRE

24/04/2015

23/04/2016

1

1500000001250

KLINIK SATELIT 1 RS PKT

JL. IMAM BONJOL BONTANG

2

1500000001249


JL. POROS BENGALON - SANGKULIRANG SEPASO TIMUR - BENGALON

3

1500000001248


JL. LETJEND S. PARMAN NO 5 BONTANG

4

1400000000342

RS PUPUK KALTIM PRIMA SANGATTA

5

1500000000946

6

7

KANTOR CABANG

NO

KODE POS

KODE PROVIDER

:

24800

S04- KANTOR CABANG BERAU

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-1506142935

PUSKESMAS GUNUNG TABUR

JL. BANGSAWAN RT 02 GUNUNG TABUR KAB. BERAU

77352

DINAS KESEHATAN KABUPATEN BERAU

PER/06/122015

RS.TRAUMA CENTRE

20/01/2016

01/12/2016

2

7-1507943081


JL. H. ISA I KEL. GAYAM KEC. TANJUNG REDEB KAB. BERAU

77311


PER/06/122015

RS.TRAUMA CENTRE

20/01/2016

01/12/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

7-1506142939

PUSKESMAS SAMBALIUNG

MANGKUBUMI II RT 007 SAMBALIUNG, KAB. BERAU

77371


PER/06/122015

RS.TRAUMA CENTRE

20/01/2016

01/12/2016

4

7-1506142933

PUSKESMAS TELUK BAYUR

JL. KANDANG MUNTIK, KEL. TELUK BAYUR KAB. BERAU

77315


PER/06/122015

RS.TRAUMA CENTRE

20/01/2016

01/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

T00- KANTOR CABANG MANADO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000815

KLINIK PRIMA HUSADA

JL. ARNOLD MONONUTU KEL. SARONGSONG II AIRMADIDI

891938

CHRISTOPORUS BUDIONO

16/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

2

1400000000069

PRAKTEK DR. FRANS PALILIEWU

JLN. SUTOYO NO. 106 KOTAMOBAGU

21192

DR. FRANS PALILIEWU

PER/04/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

3

1400000000069

PRAKTEK DR. FRANS PALILIEWU

JLN. SUTOYO NO. 106 KOTAMOBAGU

21192

DR. FRANS PALILIEWU

PER/04/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

4

1400000000428

PT SILOAM INTERNATIONAL HOSPITAL MANADO

JLN. SILOAM NO. 6 LIPPO VILLAGE TANGERANG

DR. ANDRY, M.M M.H.KES

PER/23/112015

RS.TRAUMA CENTRE

28/01/2016

31/12/2017

5

02412

RS BUDI MULIA BITUNG

JL YOS SUDARSO BITUNG

21332

DR. JOHANNIS ANDRIES NAJOAN MKES. SPFK.DK

PER/22/10/2015

RS.TRAUMA CENTRE

28/01/2016

31/12/2017

6

1400000000066

RS KINAPIT

JLN. JENDRAL S PARMAN NO. 201 KOTAMOBAGU

21192

DR. FRANS PALILIEWU

PER/03/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

7

1400000000068

RS ROBERT WOLTER MONGISIDI

JLN. 14 FEBRUARI TELING ATAS

876087

DR. ADHY SUGIH ARTO

PER/05/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

1400000000067

RS SITTI MARYAM

JLN. POGIDON RAYA NO. 110 KEC. TUMINTING

851577

DR. ANY RACHMAN

PER/02/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

9

1400000000169

RSUD BOLAANG MONGONDOW SELATAN

JALAN RAYA MOLIBAGU BOLAANG MONGONDOW SELATAN

2629444

DR. TANTI KOROMPOT

PER/10/032015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

10

1400000000175

RSUD BOLAANG MONGONDOW UTARA

JALAN TALAGA TOMOAGU BOLANGINTANG

085241745 656

DR SUGENG HERMAWAN

PER/11/032015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

11

1400000000059

RUMAH SAKIT ANGKATAN LAUT

JALAN YOS SUDARSO NO. 26 BITUNG

35030

DR. SUJOKO PURNOMO, SP.B

PER/12/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

12

1500000000352

RUMAH SAKIT BHAYANGKARA MANADO

JALAN SAM RATULANGI NO. 326 MANADO

DRG. IGNATIUS HENDRA ARIFIANTO

PER/01/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

13

1500000000085

RUMAH SAKIT BUDI MULIA BITUNG

JL. SAM RATULANGI X/9A BITUNG

LUCI

PER/022/10/2015

RS.TRAUMA CENTRE

28/01/2016

31/12/2017

14

1500000000816

RUMAH SAKIT LANUD SAM RATULANGI MANADO

JL. A.A MARAMIS - LAPANGAN MANADO

811077

DR. DIAN MULYAWARMAN, SP.M

PER/17/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

15

1400000000168

RUMAH SAKIT UMUM DAERAH AMURANG

JALAN TRANS SULAWESI, AMURANG BARAT

085341986 277

DR EINE CH ESTER KODONGAN

PER/09/032015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

16

1500000000410

RUMAH SAKIT UMUM DAERAH LAPANGAN SAWANG

KEL. SAWANG PULAU SIAU KAB. KEPL. SITARO

DR BOBBY HAN INKIRIWANG

PER/13/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

17

1500000000217

RUMAH SAKIT UMUM DAERAH LIUNKENDAGE TAHUNA

JLN. TATEHE KEL APENGSEMBAKA KEC TAHUNA

DR BLESSING ROMPIS

PER/016/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

18

1500000000227

RUMAH SAKIT UMUM DAERAH TALAUD

DESA MALA KEC. MELONGUANE TALAUD

DR JAWALI JURRY EKTIVIANUS M.KES

PER/017/022015

RS.TRAUMA CENTRE

01/02/2015

31/01/2016

KANTOR CABANG

MA11222I

:

T01- KANTOR CABANG PALU


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

1

1500000000952

POLIKLINIK PT. HARDAYA INTI PLANTATIONS

PT. HARDAYA INTI PLANTATIONS

2

1400000000290

PUSKESMAS SALAKAN

SALAKAN KABUPATEN BANGGAI KEPULAUAN

3

1400000000054

RSD. MADANI

JL. THALUAKOJI NO. 11 PALU

491470

4

1400000000081

RSU LUWUK

JL. IMAM BONJOL NO. 14 LUWUK

21820

5

1400000000083

RSU. ANUTAPURA

JL. KANGKUNG NO. 01 PALU

462770

6

1400000000440

RSUD AMPANA

JL. SULTAN HASANUDDIN NO. 32 AMPANA

7

1400000000140

RSUD ANUNTALOKO

JL. SIS ALJUFRI NO.214 KEL. MASIGI KAB.PARIGI

8

1400000000438

RSUD BUOL

JL. DR. WAHIDIN SUDIROHUSODO KEL. LEOK II KEC. BIAU KAB. BUOL

9

1400000000231

RSUD KABELOTA

JL. TRANS SULAWESI KAB. DONGGALA

10

1400000000325

RSUD KOLONODALE

JL. WOLTER MONGINSIDI NO.2 MOROWALI

11

1400000000118

RSUD MOKOPIDO

JL. LANONI NO. 37

12

1400000000324

RSUD MOROWALI

JL. TRANS SULAWESI FONUASINGKO BUNGKU

MA11222I

PIMPINAN

3149088

21032

TIPE IKS

AWAL IKS

AKHIR IKS

IR. YANI ANSHORI

PER/008/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DR. JAMES HD PINONTOAN

PER/16/082015

RS.TRAUMA CENTRE

14/01/2016

31/07/2016

PER/003/022015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

DR. YUSRAN KASIM ME

PER/011/062015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

DR RENNY A LAMADJIDO, SPPK

PER/004/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

PER/017/082015

RS.TRAUMA CENTRE

01/11/2015

31/10/2016

PER/010/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/018/082015

RS.TRAUMA CENTRE

01/11/2015

31/10/2016

PER/007/052015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

PER/013/082015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

ABD. KADIR H. TAHIR SP.PD

PER/019/102015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DR. SANDRA SUSANTY

PER/014/082015

RS.TRAUMA CENTRE

01/09/2015

31/08/2016

DR. REVY J.N TILAAR

DRG. HAMZAH ARIFANDI, M.KES


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

TIPE IKS

AWAL IKS


DRG. HARI SETIYONO

PER/005/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DR. ABDULLAH DHSM.M.KES

PER/009/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

DR. MERDY CORRY MAWUNTU

PER/020/102015

RS.TRAUMA CENTRE

01/12/2015

30/11/2016

JL. DR. SUHARSO LORONG III NO. 02

KOMPOL DR. JUDY DERMAWAN

PER/32/122014

RS.TRAUMA CENTRE

01/12/2015

30/11/2016

JL. SISINGAMANGARAJA NO .04 PALU

DR. HARIYADI AM, SP.PD

PER/021/102015

RS.TRAUMA CENTRE

01/12/2015

30/11/2016

JL. JEND. SUDIRMAN NO. 33 POSO

14

1500000000735

RSUD TORA BELO

JL. POROS PALU-PALOLO DESA SIDERA

15

1400000000119

RSUD UNDATA

JL. RE MARTADINATA KEL. TONDO PALU

16

1400000000577

RUMAH SAKIT BALA KESELAMATAN

JL. WOODWARD NO. 01 PALU

17

1400000000628

RUMAH SAKIT BHAYANGKARA

18

1400000000588

RUMAH SAKIT WIRABUANA

KODE PROVIDER

NO IKS

01/08/2015

RSUD POSO

NO

PIMPINAN

RS.TRAUMA CENTRE

1400000000277

:

IKS TELEPON

PER/012/072015

13

KANTOR CABANG

KODE POS

456099

T02- KANTOR CABANG GORONTALO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000879

PUSKESAMAS ASPARAGA

DESA BULULI KEC ASPARAGA KAB GORONTALO

DINAS KESEHATAN KABUPATEN GORONTALO

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

2

1500000000908

PUSKESMAS BATUDAA

DESA PANYUNGA KEC BATUDAA


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

3

1500000000886

PUSKESMAS BATUDAA PANTAI

JL TRANS SULAWESI KM 38 DESA KAYUBULAN KEC BATUDAA PANTAI KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000000877

PUSKESMAS BILATO

DESA BILATO KEC BOLIYOHUTO KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

5

1500000000906

PUSKESMAS BILUHU

DESA LOBUTO KEC BILUHU KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

6

1500000000883

PUSKESMAS BOLIYOHUTO

DESA SIDOMULYO KEC BOLIYOHUTO KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

7

1500000000880

PUSKESMAS BUHU

DESA BUHU KEC TIBAWA KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

8

1500000000884

PUSKESMAS DUNGALIYO

DESA KALIYOSO KEC BONGOMEME KAB GORONTALO

DINAS KESEHATAN KAB GORONTALO

PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

9

1500000000864

PUSKESMAS LIMBOTO

JL TILONGKABILA KEL HEPUHULAWA KEC LIMBOTO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

10

1500000000870

PUSKESMAS LIMBOTO BARAT

JL TRANS SULAWESI DESA YOSONEGORO KEC LIMBOTO BARAT


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1500000000881

PUSKESMAS MOLOPATODU

DESA MOLOPATODU KEC BONGOMEME KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

12

1500000000875

PUSKESMAS MOOTILANGO

DESA PARIS KEC MOOTILANGO KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

13

1500000000876

PUSKESMAS PILOHAYANGA

DESA DULOHUPA KEC TELAGA KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

14

1500000000878

PUSKESMAS PULUBALA

DESA PONGONGAILA KEC PULUBALA KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

15

1500000000885

PUSKESMAS TABONGO

DESA TABONGO BARAT KEC TABONGO KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

1500000000910

PUSKESMAS TELAGA

JALAN LIMBOTO RAYA DESA MONGOLATO KEC TELAGA


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

17

1500000000905

PUSKESMAS TELAGA BIRU

JL LIMBOTO RAYA DESA TULADENGGI KEC TELAGA BIRU


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

18

1500000000907

PUSKESMAS TELAGA JAYA

DESA HUTADAA KEC TELAGA JAYA KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

19

1500000000904

PUSKESMAS TIBAWA

DESA ISIMU SELATAN KEC TIBAWA KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

20

1500000000909

PUSKESMAS TILANGO

DESA TILOTE KEC TILANGO KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

21

1500000000874

PUSKESMAS TOLANGOHULA

DESA SUKA MAKMUR KEC TOLANGOHULA KAB GORONTALO


PER/06/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

22

1400000000104

RSUD M.M.DUNDA

JLN ACHMAD A. WAHAB NO 53 KEC LIMBOTO

RSUD DR M.M DUNDA

PER/03/042015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

23

1400000000477

RSUD OTANAHA

JL RAMBUTAN NO 413 KEL BULADU KEC KOTA BARAT

RSUD OTANAHA

PER/10/112014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

24

1400000000102

RSUD PROF DR. H. ALOEI SABOE

JL PROF DR H ALOEI SABOE KEL WONGKADITI TIMUR


PER/04/042015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

25

1400000000102


JL PROF DR H ALOEI SABOE KEL WONGKADITI TIMUR


PER/04/042015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1400000000103

RSUD TANI DAN NELAYAN

JL TRANS SULAWESI KAB BOALEMO

PER/15/102015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

27

1400000000155

RSUD TOTO KABILA

JL KESEHATAN NO 25 DESA PERMATA KEC TILONGKABILA

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

881455

8701943

RSUD TOTO KABILA


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Periode : 01012015 s/d 31122016

NO

28

KODE PROVIDER

RUMAH SAKIT ISLAM GORONTALO

1500000001830

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

:

ALAMAT

KODE POS

JL PROF DR HB JASSIN NO 457 KOTA GORONTALO

IKS TELEPON

PIMPINAN NO IKS

830820

YAYASAN KESEJAHTERAAN UMAT HASANAH GORONTALO

PER/04/052015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/05/2015


W00- KANTOR CABANG MAKASSAR

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000110

BALAI LATIHAN KERJA INDUSTRI MAKASSAR

JL TAMAN MAKAM PAHLAWAN NO 4

PER/41/122014

RS.TRAUMA CENTRE

06/01/2015

06/01/2016

2

1500000000032

BALAI LATIHAN KERJA INDUSTRI MAKASSAR

JL.TAMAN MAKAM PAHLAWAN NO 4

PER/41/122014

RS.TRAUMA CENTRE

06/01/2015

06/01/2016

3

1400000000117

HEALTH AND NUTRITION CLINIC

JL PERINTIS KEMERDEKAAN KM 8 KOMP RUKO ANTARA NO 25

581983

PROF.DR.DR.HJ.SURYANI AS'AD M,SC,SP.GK

PER/31/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

4

07808

KLINIK PAJJAIANG

JLN PAJJAIANGRUKO PELANGI NO 1

399696477

RUSMAN,S.SI.APT

PER/37/062015

KAPITASI

01/06/2015

31/05/2016

5

07678

KLINIK SEHAT 24 JAM MAKASSAR

JLN PENGAYOMAN RUKO PERMATSARI NO 3

2940091

DR MUH FIRDAUS KASIM

PER/36/062015

FFS

01/06/2015

31/05/2016

6

1400000000075

KLINIK SEROJA

JL. GOA RIA NO. 106 SUDIANG

550228

DR. MOH. HELMY JUSUF

PER/27/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

7

1400000000161

PUSKESMAS BUNGORO

KECAMATAN BUNGORO KAB PANGKEP

4291557

DRG ANWAR NUHUNG

PER/21/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

8

1400000000170

RS AKADEMIS JAURY JUSUF PUTERA

JL JEND M JUSUF NO 57 A MAKASSAR

317343

PER/29/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

9

1400000000044

RS AWAL BROS MAKASSAR

JL. JENDRAL URIP SUMOHARJO NO. 43

454567

PT MAKASSAR GLOBAL AWAL BROS

PER/25/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

10

1400000000046

RS ISLAM FAISAL MAKASSAR

JALAN ANDI PANGERAN PETTARANI MAKASSAR

871942

PROF DR H SYAFRUDDIN WAHID PHD,SP,PA(K)

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

11

1500000000332

RS TNI AU DR DODY SARJOTO

JL DAKOTA NO. 1 LANUD SULTAN HASANUDDIN

553185

PER/01/032015

RS.TRAUMA CENTRE

16/03/2015

31/12/2016

12

1500000000333

RSU HIKMAH

JL YOSEF LATUMAHINA NO 1

872284

PER/45/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

13

1400000000190

RSUD ANDI MAKASSAU

JL NURUSSAMAWATI NO 9 PAREPARE

21163

PER/23/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

14

1500000000033

RSUD HAJI MAKASSAR

JL DG MASEPPE

PER/43/122014

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

15

1400000000171

RSUD HAJI PADJONGA DAENG NGALLE

JL INCE HUSEIN DAENG PARANI NO 1

PER/20/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

16

1400000000345

RSUD LAMADUKELLENG SENGKANG WAJO

JL KARTIKA CANDRA KIRANA SENGKANG

PER/19/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

17

1400000000173

RSUD LANTO DAENG PASEWANG

JL LINGKAR KARISA BONTOSUNGGU NO

PER/24/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

18

1400000000195

RSUD LATEMMAMALA

JL MALAKA RAYA WATANSOPPENG

PER/30/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

19

1400000000189

RSUD PANGKEP

JL ST HASANUDDIN KABUPATEN PANGKEP

2311118

PER/02/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

20

1400000000172

RSUD SALEWANGANG MAROS

JL POROS MAROS MAKASSAR KM 3

371166

PER/28/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I

II.DR. H. KAMARUDDIN SAID, SP.B, MARS

21065

21004

ARMAN


SM0480



314 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

21

1400000000077

RSUD SAYANG RAKYAT MAKASSAR

JL. PAHLAWAN NO. 1000 KEL. BULUROKENG KEC. BIRINGKANAYA

5068931

PEMERINTAH PROVINSI SULAWESI SELATAN

PER/18/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

22

1400000000213

RSUD SINJAI

JL. JEND SUDIRMAN NO 47 KEL BIRINGERE KEC SINJAI UTARA

21132

PEMDA KAB SINJAI

PER/22/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

23

1500000000480

RSUD SYEKH YUSUF KABUPATEN GOWA

JL DR WAHIDIN SUDIRO HUSODO NO 48 SUNGGUMINASA

99257248

PER/14/022015

RS.TRAUMA CENTRE

14/01/2015

14/01/2016

24

1500000000111

RSUP DR WAHIDIN SUDIROHUSODO MAKASSAR

JL PERINTIS KEMERDEKAAN KM 11 TAMALANREA

PER/05/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

25

1400000000162

RUMAH SAKIT BHAYANGKARA MAKASSAR

JL. LETJEND. POL. MAPPAOUDANG NO. 63

PER/26/032015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

26

1500000001893

SILOAM HOSPITALS

JL METRO TANJUNG BUNGA KAV 9

PER/34/052015

RS.TRAUMA CENTRE

07/04/2015

06/04/2017

KANTOR CABANG

NO

KODE PROVIDER

:

836344

90134

KEPOLISIAN NEGARA REPUBLIK INDONESIA

3662900

W01- KANTOR CABANG KENDARI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-477552713

BLUD RSU BAHTERA MAS SULTRA

JL KAPTEN PIERE TENDEAN

93114

PEMDA PROV SULTRA

PER/002/042015

RS.TRAUMA CENTRE

24/11/2015

31/03/2017

2

7-477552713

BLUD RSU BAHTERA MAS SULTRA

JL KAPTEN PIERE TENDEAN

93114

PEMDA PROV SULTRA

PER/002/042015

RS.TRAUMA CENTRE

04/12/2015

01/04/2017

3

1500000000583

PUSKESMAS ABELI

JL SEWANGI NO 2 KEL ABELI KEC ABELI

DINAS KESEHATAN KOTA KENDARI

PER/03/042015

RS.TRAUMA CENTRE

16/04/2015

15/04/2016

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000001056

RS TNI AD TK.IV DR R ISMOYO

JL. LAUTE NO. 1 KENDARI

KODAM VII WIRABUANA

PER/04/052015

RS.TRAUMA CENTRE

25/05/2015

24/05/2016

5

1400000000062

RSUD ABUNAWAS KOTA KENDARI

JL BRIGJEN Z.A SUGIANTO NO.39

DINAS KESEHATAN KOTA KENDARI

PER/004/012016

RS.TRAUMA CENTRE

05/01/2016

04/02/2017

6

1500000000526

RUMKIT BHAYANGKARA KENDARI.

JL. Y WAYONG NO. 7

POLDA SULAWESI TENGGARA

PER/02/042015

RS.TRAUMA CENTRE

14/04/2015

13/04/2017

KANTOR CABANG

NO

KODE PROVIDER

:

3121253

W02- KANTOR CABANG PALOPO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000095

ANNIDA WOUND CARE CENTRE

JL PATIMURA SAMPING KANTOR BAPEDA

14201909

PAK ASWARDI, DR SYUKUR

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

2

1500000001802

DR ADI SASTRAWIJATA SP.B

JL POROS BELOPA PALOPO

342620237

DR ADI SASTRAWIJAYA

PER/11/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

3

1500000001332

DR ERICK GAMALIEL AMBA M.KES SP.OT

JL ANDI DJEMMA NO 06 PALOPO

357401801

DR ERICK GAMALIEL AMBA M.KES SP.OT

PER/10/062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

4

1500000000097

DR YAIN PANGGALO

JL PONGTIKU RANTEPAO

255009811

DR YAIN PANGGALO

PER/02/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

5

1500000000096

LEONY WOUND CARE

JL SUNAGI PAREMAN PAMMANU

398362717

ASRIEL TALARAN DAN DR DR MAHDUR

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

6

1500000000098

PUSKESMAS BUA

JL TANDIPAU KEC BUA PALOPO

342718401

DR BUNADI

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

MA11222I


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Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

1400000000049

RS BINTANG LAUT

JL K.H.M. KASIM NO 5

21302

YAYASAN RATNA MIRIAM

PER/12/032015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

8

1500000000128

RS HIKMAH

JL IR SOEKARNO KEL KAPUNNA KEC MASAMBA

87248801

DR ISWANTO

PER/06/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

9

1500000000838

RSU AT MEDIKA PALOPO

JL ANDI DJEMMA NO 06

97822888

YAYASAN AT MEDIKA

PER/07/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

10

1500000000868

RSUD LAKIPADADA

JL PONGTIKU MANDETEK TANA TORAJA

PEMDA KAB TANA TORAJA

PER/09/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

11

1500000000094

RSUD NENE MALLOMO

JL. WOLTER MONGINSIDI PANGKAJENE MARITENGNGAE KAB. PANGKAJENE SIDRAP

081244749 330

DRG. HJ. HASNANI RAPI, M.KES

PER/05/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

12

1500000000869

RUMAH SAKIT UMUM ELIM RANTEPAO

JL A. YANI NO 68 RANTEPAO

21258

YAYASAN KESEHATAN GEREJA TORAJA

PER/08/052015

RS.TRAUMA CENTRE

01/05/2015

30/04/2016

KANTOR CABANG

NO

KODE PROVIDER

:

X00- KANTOR CABANG BALI DENPASAR

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000504

BLK PROPINSI BALI

JL IMAM BONJOL 603 DENPASAR

UPT BLK-IP BALI

PER/05/022015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

2

1500000000100

DR NI PUTU DIAN SULISTYAWATI, MM (24 JAM)

RUKO BLOK I-J DALUNG JL PADANG LIWIH NO 143 DALUNG

DR NI PUTU DIAN SULISTYAWATI, MM

PER/01/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

3

1500000000139

KLINIK ANUGERAH

JL NANGKA NO 87 A DENPASAR

PER/03/012015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

MA11222I


SM0480



317 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

4

1500000000078

KLINIK UTAMA PADMA BAHTERA MEDICAL CENTRE

JL HAYAM WURUK NO 240

246701

5

1500000000451

RS BHAYANGKARA TRIJATA

JL TRIJATA NO 32

222908

6

1500000000453

RS INDERA PROVINSI BALI

JALAN ANGSOKA NO. 8

7

1500000001931

RS KASIH IBU DENPASAR

JL. TEUKU UMAR NO 120 DENPASAR

80111

8

1500000001933

RS KASIH IBU KEDONGANAN

JL. ULUWATU NO 69A KEDONGANAN JIMBARAN BADUNG

9

1500000001932

RS KASIH IBU TABANAN

JL. FLAMBOYAN NO 9 BR TEGAL BELODAN TABANAN

10

1400000000484

RS SURYA HUSADHA DENPASAR

JL PULAU SERANGAN NO 7 DENPASAR

11

1400000000483

RS SURYA HUSADHA UBUNG

JL COKROAMINOTO NO 356

12

1200000000017

RSU BHAKTI RAHAYU DENPASAR

JL GATOT SUBROTO II NO 11 DENPASAR

430270

13

1200000000017

RSU BHAKTI RAHAYU DENPASAR

JL GATOT SUBROTO II NO 11 DENPASAR

430270

14

1400000000554

RSU PARAMA SIDHI

JLN. AHMAD YANI NO. 171A SINGARAJA

32701

15

7-204036033

RSU PURI RAHARJA DENPASAR

JL WR SUPRATMAN NO 14 & 19 DENPASAR

MA11222I

PIMPINAN TIPE IKS

AWAL IKS

AKHIR IKS

PER/19/122014

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

POLRI

PER / 06 / 022015

RS.TRAUMA CENTRE

01/03/2015

28/02/2017

DR. NI MADE YUNITI., MM

PER/09/032015

RS.TRAUMA CENTRE

01/04/2015

31/12/2016

3003030

PER/19/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2016

80351

703270

PER/21/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2016

82111

5003737

PER/20/082015

RS.TRAUMA CENTRE

01/08/2015

31/12/2016

233787

PER/02/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

PER/01/2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

PUTU IVAN YUNATANA

PER/05/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

PUTU IVAN YUNATANA

PER/12/112014

RS.TRAUMA CENTRE

01/01/2015

31/10/2015

PER/06/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

PER/31/102015

RS.TRAUMA CENTRE

06/11/2015

31/12/2016

80232

036122201 3

RSU PURI RAHARJA DENPASAE


SM0480



318 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

16

1500000000140

RSU SHANTI GRAHA

DSN TAMANSARI DESA SULANYAH SERIRIT SINGARAJA

94554

17

1400000000482

RSU SURYA HUSADHA NUSA DUA

JL SILIGITA BLOK I NO 14 NUSA DUA

766154

18

1500000000653

RSU TABANAN

JL. PAHLAWAN NO. 14 TABANAN

811027

19

1500000000655

RSUD BADUNG

JL. RAYA KAPAL MENGWI, BADUNG

20

1500000000654

RSUD WANGAYA

21

1400000000485

SILOAM HOSPITAL BALI

KANTOR CABANG

NO

KODE PROVIDER

:

PT MEKAR SHANTI GRAHA

TIPE IKS

AWAL IKS

AKHIR IKS

PER/02/012015

RS.TRAUMA CENTRE

01/02/2015

31/12/2015

PER/03/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

DR I NYOMAN SUSILA, M.KES

PER/13/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2016

9006812

DR. AGUS BINTANG SURYADHI, M.KES.

PER/15/042015

RS.TRAUMA CENTRE

01/06/2015

31/12/2016

JL. KARTINI NO.133 DENPASAR

222141

DR. SETIAWATI HARTAWAN,M.KES

PER/14/042015

RS.TRAUMA CENTRE

01/05/2015

31/12/2016

JALAN SUNSET ROAD NO 818 KUTA

779900

PER/04/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

X01- KANTOR CABANG KUPANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

1

1100000000003

PROF DR WZ JOHANNES KUPANG

JL M HOTTA NO 19

2

1400000000288

RS BHAYANGKARA KUPANG

JL NANGKA 84 KUPANG

85111

821999

3

1400000000288

RS BHAYANGKARA KUPANG

JL NANGKA 84 KUPANG

85111

821999

MA11222I

PIMPINAN

TIPE IKS

AWAL IKS

AKHIR IKS

PER/ 002/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

POLRI / POLDA NTT

PER/ 017/ 102015

RS.TRAUMA CENTRE

22/01/2016

31/12/2016

POLRI / POLDA NTT

PER/ 017/ 102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016


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319 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PT KARTINI MEDIKAL KUPANG

PER/ 018 /102015

RS.TRAUMA CENTRE

04/11/2015

30/09/2016

TNI AL

PER/15/ 062015

RS.TRAUMA CENTRE

01/06/2015

31/05/2016

JALAN MOH HATTA NOMOR 11 KUPANG

PER/ 09/ 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

RSUD BA'A KABUPATEN ROTE NDAO

JALAN BUSALANGGA BA'A

PER/ 08/ 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

1400000000417

RSUD DR TC HILLERS MAUMERE

JALAN WAIRKLAU MAUMERE

PER/ 005/ 012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

9

1500000000064

RSUD KAB SABU RAIJUA

JALAN TRANS SEBA BOLOU KM 7 MENIA SABU

PER/ 01/ 012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

10

1500000000582

RSUD KEFAMENANU KAB TTU

JALAN LERJEN SOEPRAPTO KEFAMENANU

PER/ 010 / 042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

11

1400000000565

RSUD MGR GABRIEL MANEK ATAMBUA

JALAN DR SOETOMO NO 02 ATAMBUA

PER/ 003/ 012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

12

1400000000418

RSUD NAIBONAT KABUPATEN KUPANG

JALAN TIMOR TAYA KM 37 OELAMASI

85223

PER/ 019/ 102015

RS.TRAUMA CENTRE

01/11/2015

13

1400000000418

RSUD NAIBONAT KABUPATEN KUPANG

JALAN TIMOR TAYA KM 37 OELAMASI

85223

PER/ 019/ 102015

RS.TRAUMA CENTRE

17/12/2015

31/10/2016

14

1500000000394

RSUD SOE KABUPATEN TTS

JLN CENDANA SOE

PER/07/032015

RS.TRAUMA CENTRE

01/03/2015

28/02/2016

15

1400000000394

RSUD UMBU RARA MEHA WAINGAPU

JALAN ADAM MALIK NO 54 WAINGAPU

PER/ 007/ 012016

RS.TRAUMA CENTRE

01/02/2016

30/01/2017

4

7-170855890

RS KARTINI KOTA KUPANG

JALAN FRANS SEDA NO 17 KUPANG

5

1400000000090

RS TNI AL SAMUEL J MOEDA KUPANG

JL YOS SUDARSO NO. 5 OSMOK ALAK KUPANG

6

1500000000469

RST WIRASAKTI KOTA KUPANG

7

1500000000470

8

MA11222I

85112 085242475 035

2426133

21016

61302


SM0480



320 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

16

1500000001987

RUMAH SAKIT KARTINI KOTA KUPANG

JALAN FRANS SEDA NOMOR 17 KUPANG

17

1500000000119

RUMAH SAKIT PANGKALAN TNI AU EL TARI

JL ADI SUCIPTO NO 2 KUPANG

3838123

18

1500000000119

RUMAH SAKIT PANGKALAN TNI AU EL TARI

JL ADI SUCIPTO NO 2 KUPANG

3838123

19

1400000000543

RUMAH SAKIT PENYANGGA PERBATASAN BETUN

JALAN SUKABIHANAWA DESA KAMANASA MALAKA TENGAH

20

7-1708103837

SILOAM HOSPITALS LABUAN BAJO

JALAN GABRIEL GAMPUR RT 013 RW 005 DESA GORONTALO KECAMATAN KOMODO LABUAN BAJO

21

1500000000438

UPT PELATIHAN TENAGA KERJA DINAS NAKERTRANS PROVINSI NTT

JALAN THAMRIN NO 03 KAYU PUTIH

KANTOR CABANG

NO

KODE PROVIDER

:

AWAL IKS

AKHIR IKS

PER / 018 /102015

RS.TRAUMA CENTRE

01/10/2015

30/09/2016

TNI AU

PER/ 004/ 012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

TNI AU

PER/04/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

PER/ 09/ 022016

RS.TRAUMA CENTRE

09/02/2016

09/02/2017

PER/ 006/ 012016

RS.TRAUMA CENTRE

29/01/2016

29/01/2017

PER/ 05/ 032015

RS.TRAUMA CENTRE

01/03/2015

29/02/2016

85141

86754

TIPE IKS

PT LINTAS BUANA JAYA

833270

X03- KANTOR CABANG MATARAM

NAMA PROVIDER

ALAMAT

1

1500000000500

BLK MATARAM

JL TGH HAMBALI NO. 2 MATARAM

2

1400000000390

RS BHAYANGKARA MATARAM

JL. LANGKO NO 64 MATARAM

3

1400000000429

RS HARAPAN KELUARGA

JL AHMAD YANI NO 9, SELAGALAS, MATARAM

MA11222I

PIMPINAN

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

623443

DINAS TENAGA KERJA & TRANSMIGRASI PROVINSI NTB

/464/NAKERTR ANS/III/2015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

83117

629149

DRG MUHAMMAD ZAKIR SH,MH

PER/19/102015

RS.TRAUMA CENTRE

03/12/2015

31/12/2016

83117

6177000

DR JEFFRY SUGIANTO

PER/20/112015

RS.TRAUMA CENTRE

03/12/2015

31/12/2016


SM0480



321 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1400000000276

RSU PROVINSI NTB

JALAN PEJANGGIK NO 6 MATARAM

621345

RSU PROVINSI NTB

PER/17/082015

RS.TRAUMA CENTRE

03/12/2015

31/12/2015

5

1500000000061

RSUD KABUPATEN SUMBAWA BARAT

JALAN UNDRU NO 6 KEC TALIWANG

8281057

DR HJ DWIWIDIA MERTASARI

PER/02/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

6

1400000000111

RSUD KOTA MATARAM

JL BUNG KARNO NO 3 PAGUTAN MATARAM

RSUD KOTA MATARAM

PER/04/012015

RS.TRAUMA CENTRE

02/01/2015

31/12/2015

7

1400000000110

RSUD SUMBAWA

JL GARUDA NO 5 SUMBAWA BESAR

RSUD SUMBAWA

PER/03/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

KANTOR CABANG

NO

KODE PROVIDER

:

21929

X04- KANTOR CABANG BALI GIANYAR

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

1

1500000000842

DINAS TENAGA KERJA DAN TRANSMIGRASI KAB KARANGASEM

JL AHMAD YANI NO 29 AMLAPURA

8421188

2

1500000000114

KLINIK PENTA MEDIKA

JL. RAYA MANGGIS 88

41909

3

1500000000114

KLINIK PENTA MEDIKA

JL. RAYA MANGGIS 88

41909

4

1400000000453

RSUD BANGLI

JL. BRIGJEN NGURAH RAI NO. 99X

5

1400000000395

RSUD KARANGASEM

JL. I GUSTI NGURAH RAI AMLAPURA

MA11222I

PIMPINAN TIPE IKS

AWAL IKS

AKHIR IKS

PER/1001/03201 5

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

DR. A A GEDE YUDI YUNARDHANA PUTRA

PER/009/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

DR. A A GEDE YUDI YUNARDHANA PUTRA

PER/006/012016

RS.TRAUMA CENTRE

22/01/2016

31/12/2016

91002

PER/006/112015

RS.TRAUMA CENTRE

16/12/2015

31/12/2016

21470

PER/005/102015

RS.TRAUMA CENTRE

01/10/2015

31/12/2015


SM0480



322 / 322 09-02-2016 18:49:59

Periode : 01012015 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6

1400000000473

RSUD KLUNGKUNG

JL. FLAMBOYAN NO 40 SEMARAPURA

21172

PER/005/012016

RS.TRAUMA CENTRE

22/01/2016

31/12/2016

7

1400000000321

RSUD SANJIWANI GIANYAR

JL. CIUNG WANARA NO. 2

943049

PER/004/092015

RS.TRAUMA CENTRE

01/09/2015

31/12/2015

8

1400000000321



943049

ADD/004/082015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

9

1400000000321



943049

PER/003/012016

RS.TRAUMA CENTRE

22/01/2016

31/12/2017

10

1500000000724

RUMAH SAKIT ARI ÇANTI

JL. RAYA MAS UBUD

976508

DR. I WAYAN ARYAWAN

PER/010/042015

RS.TRAUMA CENTRE

01/04/2015

31/03/2016

11

7-463005405

RUMAH SAKIT BALIMÉD KARANGASEM

JALAN NENAS, KECICANG, BEBANDEM, KARANGASEM

DR. I NENGAH SURANTEN

PER/005/112015

RS.TRAUMA CENTRE

19/11/2015

31/12/2016

12

1200000000003

RUMAH SAKIT UMUM GANESHA

JL RAYA CELUK,SUKAWATI

298233

DR. GUSTI PUTU DARMIKA.S.KED

PER/002/012016

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

13

1200000000003

RUMAH SAKIT UMUM GANESHA

JL RAYA CELUK,SUKAWATI

298233

DR. GUSTI PUTU DARMIKA.S.KED

PER/002/012015

RS.TRAUMA CENTRE

01/01/2015

31/12/2015

14

1400000000256

YAGYA DASA KLINIK

JL RAYA SENGKIDU DS SENGKIDU KEC MANGGIS

41378

DR NI WAYAN PUTU SUATI

PER/003/072015

RS.TRAUMA CENTRE

01/07/2015

30/06/2016

MA11222I

80811


SM0480

DAFTAR JEJARING TRAUMA CENTER DAN FASILITAS KERJASAMA BPJS KETENAGAKERJAAN

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