DAFTAR JEJARING TRAUMA CENTER DAN FASILITAS KERJASAMA BPJS KETENAGAKERJAAN

Halaman : Tanggal Cetak : Waktu Cetak :

DAFTAR JEJARING TRAUMA CENTER DAN FASILITAS KERJASAMA BPJS KETENAGAKERJAAN

1 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016 KANTOR CABANG

NO

1

KODE PROVIDER

001- KANTOR CABANG TERNATE

NAMA PROVIDER

RUMAH SAKIT MEDIKA HARIFALM

1500000000035

KANTOR CABANG

NO

:

:

KODE PROVIDER

ALAMAT

ALAMAT

1400000000012

KLINIK MAJU BERSAMA (KLINIK-TC)

JL BASUKI RAHMAT KM 11 (DEPAN BATALION)

2

1400000000555

KLINIK MAJU BERSAMA II AIMAS (KTC)

JL WORTEL AIMAS UNIT 2 KAB SORONG

3

04658

RS MUTIARA

JL MALEO NO 2 SORONG

4

1400000000022

RSAL DR OETOYO (RS TC)

JLN JEND AHMAD YANI

5

1400000000408

RSUD KAB RAJA AMPAT (RSTC)

JL DISTRIK WAISAI

MA11222I

PIMPINAN NO IKS DR.AZIS MANAF SP.PD

PER/001/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

22/02/2016

AKHIR IKS 31/12/2016

100- KANTOR CABANG SORONG

NAMA PROVIDER

:

IKS TELEPON

KEL KOTA BARU KOTA TERNATE

1

KANTOR CABANG

KODE POS

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR LIDIA KURNIAWAN

PER/003/032016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

13351490

DR. GINDAR SITEPU

PER/044/122015

RS.TRAUMA CENTRE

05/01/2016

30/11/2016

095132743 3

DR HJ PAHIMAH/ISKANDAR

PER/001/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

PER/002/032016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

PER/043/112015

RS.TRAUMA CENTRE

01/02/2016

31/10/2016

44717931

101- KANTOR CABANG JAYAPURA


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2 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

1500000000081

RS MARTHEN INDEY

JL. DIPONEGORO NO. 27 GURABESI

2

1400000000716

RSAL DR. SOEDIBJO SARDADI

JL. AMPHIBI NO. 1 HAMADI

KANTOR CABANG

NO

:

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1500000000127

RUMAH SAKIT AVICENNA BIREUEN

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

2

7-2060022073

RUMAH SAKIT PMI ACEH UTARA

JALAN SAMUDERA GAMPONG KAMPUNG JAWA KEC BANDA SAKTI

3

1400000000410

RUMAH SAKIT PT. ARUN NGL

JL. PLAJU KOMPLEK PT. ARUN NGL GP. BATUPHAT BARAT KEC. MUARA SATU

4

1400000000322

RUMAH SAKIT UMUM BUNDA LHOKSEUMAWE

5

1400000000691

RUMAH SAKIT UMUM BUNGA MELATI

MA11222I

:

IKS TELEPON

PIMPINAN NO IKS

522958

TIPE IKS

AWAL IKS

AKHIR IKS

RSMI JAYAPURA

PER/18/122015

RS.TRAUMA CENTRE

14/01/2016

31/12/2016

RSAL DR. SOEDIBJO SARDADI

PER/19/122015

RS.TRAUMA CENTRE

14/01/2016

31/12/2016

A00- KANTOR CABANG LHOKSEUMAWE

1

KANTOR CABANG

KODE POS

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR.FAISAL,SP.OG

PER/02/022016

RS.TRAUMA CENTRE

24/02/2016

31/12/2016

DR FERIANTO

PER/01/022016

RS.TRAUMA CENTRE

17/02/2016

31/12/2016

653165

DR. SYAHRUDDIN IBRAHIM

PER/27/102015

RS.TRAUMA CENTRE

18/02/2016

31/12/2016

JL. DARUSSALAM NO. 16 KECAMATAN BANDA SAKTI

46924

DR. HANAFIAH HASAN, SP.OG

PER/26/102015

RS.TRAUMA CENTRE

18/02/2016

31/12/2016

JL SAMUDERA BARU NO. 3 KEUDE ACEH KEC. BANDA SAKTI

44821

DR.TAUFIQ A.R

PER/03/022016

RS.TRAUMA CENTRE

26/02/2016

31/12/2016

22887

24352

A01- KANTOR CABANG BANDA ACEH


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3 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

1400000000569

CEMPAKA LIMA

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

2

1500000000056

KLINIK AA MEDICAL

3

1400000000566

4

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

HJ. KARTINI.N.I

PER/38/122015

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

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

HJ. AGUSMIATI, S.SI.T

PER/14/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

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

1400000000670

KLINIK BUNDA

JL.BANDA ACEH-MEDAN NO.1 GAMPONG BARO JAMAN KEC. MUTIARA

ITA MUTIA

PER/17/022016

RS.TRAUMA CENTRE

22/02/2016

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/08/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

6

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

7

1500000000153

KLINIK KIMIA FARMA

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

M. BAGUS ANDREAS TAUFANI, S.FARM, APT

PER/11/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

8

1500000001919

KLINIK MITRA MEDISTRA

JL. RESIDEN DANUBROTO GP. LAMLAGANG KEC. BANDA RAYA

23111

AZIZURRAHMAN, SKM,MM

PER/10/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

9

7-1676350253

KLINIK RANUP PEUNAWA MEDIKA

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

23352

CAPT. FADLI, SE, M.MAR

PER/05/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

10

1400000000677

KLINIK RAWAT INAP MINA

JL.LAKSAMANA MALAHAYATI KM.7 GP.BAET KEC.BAITUSSALAM KAB. ACEH BESAR

DR. RAHMI

PER/13/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

11

1400000000673

KLINIK SIWAH MEDIKA CENTER

JL.T.P. POLEM NO. 168-174 GP.PEUNANYONG, KEC. KUTA ALAM KOTA BANDA ACEH

LYDIA SEPTA DESIYANA, M.SI, APT

PER/12/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

12

1500000000242

KLINIK UMMI AISYAH

JL. PERDAGANGAN GAMPONG KUTA BARAT KOTA SABANG

MINALTIWATI, AMD.KEB

PER/18/022016

RS.TRAUMA CENTRE

27/02/2016

31/12/2016

MA11222I

33345

21536

72303666


SM0480



4 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

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

14

1400000000073

RS HARAPAN BUNDA

JL T UMAR NO 181-185 GP SEUTUI

48114

DR. ZAINAL BAKRI SPOG

PER/07/022016

RS.TRAUMA CENTRE

25/02/2016

31/12/2016

15

1400000000073

RS HARAPAN BUNDA

JL T UMAR NO 181-185 GP SEUTUI

48114

DR. ZAINAL BAKRI SPOG

PER/15/032015

RS.TRAUMA CENTRE

15/02/2016

24/02/2016

16

1400000000692

RSUD KABUPATEN PIDIE JAYA

JL. BANDA - ACEH KM. 158, MEUREUDU KABUPATEN PIDIE JAYA

PER/09/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

17

7-2017798742

RSUD ZAINOEL ABIDIN

JL. TGK H.M DAUD BEUREUEUH NO 108 BANDA ACEH

23121

60668923

DR. FACHRUL JAMAL, SP. AN. KIC

PER/16/022016

RS.TRAUMA CENTRE

15/02/2016

31/12/2018

18

7-2017798742

RSUD ZAINOEL ABIDIN

JL. TGK H.M DAUD BEUREUEUH NO 108 BANDA ACEH

23121

60668923

DR. FACHRUL JAMAL, SP. AN. KIC

PER/16/022016

RS.TRAUMA CENTRE

16/02/2016

31/12/2016

19

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

20

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

21

1400000000570

RUMAH SAKIT U'BUDIYAH

7555750

PT. CAISARIO ROYAL PRATAMA

PER/35/122015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

KANTOR CABANG

MA11222I

:

A02- KANTOR CABANG LANGSA


SM0480



5 / 108 02-03-2016 13:40:34

Periode : 01012016 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

1500000000037

PUSKESMAS BANDAR PUSAKA

KECAMATAN BANDAR PUSAKA

085363910 858

SYAMSUDDIN, SKM

PER/04/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2017

4

1500000000040

PUSKESMAS SEKERAK

KECAMATAN SEKERAK

082168103 036

DR. ABDUL GAFUR

PER/03/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2017

5

1400000000340

RSU CUT MEUTIA

JL GARUDA NOMOR 1 KEBUN BARU KECAMATAN LANGSA BARO

23071

IR EDDY PURNOMO

PER/25/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

6

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

7

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

8

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

9

1400000000674

RUMAH SAKIT UMUM UMMI

JL PROF A.MAJID IBRAHIM DUSUN SATRIA RT 02 SUNGAI PAUH KECAMATAN LANGSA BARAT

22886

DR. SAID MUHAMMAD FACHRIANSYAH

PER/19/012016

RS.TRAUMA CENTRE

16/02/2016

31/12/2016

10

1400000000674

RUMAH SAKIT UMUM UMMI

JL PROF A.MAJID IBRAHIM DUSUN SATRIA RT 02 SUNGAI PAUH KECAMATAN LANGSA BARAT

22886

DR. SAID MUHAMMAD FACHRIANSYAH

PER/19/012016

RS.TRAUMA CENTRE

15/02/2016

15/02/2017

KANTOR CABANG

MA11222I

:

A03- KANTOR CABANG MEULABOH


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6 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

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

4

1400000000611

KLINIK JEUMPA MEDICA

JL. GAJA MADA NO.40 MEULABOH

DR. MUTIA DARMAWAN

PER/13/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

1500000000012

PUSKESMAS ALUE BILIE

JL. ERWIN IBRAHIM, KEC. DARUL MAKMUR

23662

AJA PUTRI

PER/03/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6

1500000000002

PUSKESMAS ALUE RAMBOT

DESA ALUE RAMBOT, KEC. DARUL MAKMUR

23662

DR, CHAIDIR

PER/20/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7

1500000000013

PUSKESMAS BEUTONG

LHOK SEUMOT, KEC.BEUTONG

23672

HJ. NURLIMPAH

PER/10/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

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

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

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

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

MA11222I


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8 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

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

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

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

34

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

35

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

36

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

MA11222I

23654


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

37

1500000000015

RSUD TEUNGKU PEUKAN

BLANG PIDIE,ACEH BARAT DAYA

38

1400000000614

RUMAH SAKIT TINGKAT IV IM 07.02 MEULABOH

JL. MERAH PUTIH GAMPONG SUAK INDRAPURI KEC. JOHAN PAHLAWAN

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

IKS TELEPON

PIMPINAN NO IKS

92522

TIPE IKS

AWAL IKS

AKHIR IKS

DARUSMAN, M.KES (MMR)

PER/11/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KAPTEM CKM DR. TEGUH ISMANTO,SP.AN

PER/16/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1400000000127

BP HARAPAN BUNDA

JL. BRIGJEND ZEIN HAMID NO 39 TITI KUNING

7852636

NETTY BARITA, SE

PER/13/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

3

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

4

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

5

1500000000201

BP KURNIA

JL BINJAI KM 8.8 NO 11 KP LALANG MEDAN

850915

TAN ERFI

PER/20/022016

RS.TRAUMA CENTRE

22/02/2016

31/12/2016

6

1500000000201

BP KURNIA

JL BINJAI KM 8.8 NO 11 KP LALANG MEDAN

850915

TAN ERFI

PER/18/022016

RS.TRAUMA CENTRE

18/02/2016

17/02/2017

7

1500000000199

KLINIK ADISMA HUSADA DARUSSALAM

JL DARUSSALAM NO 5A

4153169

DR H SAYID BUDHI

PER/16/022016

RS.TRAUMA CENTRE

17/02/2016

31/01/2017

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

1500000000198

KLINIK ADISMA HUSADA TEMBUNG

JL BESAR MEDAN BATANG KUIS DSN XI TEMBUNG

7383103

DR SAYID BUDHI

PER/17/022016

RS.TRAUMA CENTRE

17/02/2016

31/01/2017

9

1500000000196

KLINIK AKSARA

JL AKSARA NO 120 MEDAN

97374384

TEGUH SUHARTO, SE

PER/23/022016

RS.TRAUMA CENTRE

24/02/2016

31/12/2016

10

1500000000206

KLINIK AVIATI 1

JL JAMIN GINTING NO 15 P BULAN MEDAN BARU

6103683

DRG AMETA PRIMASARI TARIGAN

PER/19/022016

RS.TRAUMA CENTRE

18/02/2016

31/01/2017

11

1500000000207

KLINIK AVIATI 3

JL JAMIN GINTING KM 8.5 KOMP DELTA NO 5 MEDAN TUNTUNGAN

3436450

DRG AMETA PRIMASARI TARIGAN

PER/21/022016

RS.TRAUMA CENTRE

22/02/2016

31/12/2016

12

1500000000203

KLINIK AZIZZI GATOT SUBROTO

JL JEND GATOT SUBROTO NO 333 MEDAN

4155528

DRS H RAZALI ROHIMUN

PER/26/022016

RS.TRAUMA CENTRE

24/02/2016

31/12/2016

13

1500000000202

KLINIK AZIZZI SUMARSONO

JL KAPT SUMARSONO NO 74 MEDAN

80030330

DR RIYADH IKHSAN

PER/25/022016

RS.TRAUMA CENTRE

24/02/2016

31/12/2016

14

1500000000194

KLINIK BERSAMA

JL JAMIN GINTING NO 502 P BULAN MEDAN

68272131

SAMPE REZEKI, SE

PER/24/022016

RS.TRAUMA CENTRE

24/02/2016

31/12/2016

15

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

16

1500000000195

KLINIK GRIYA MEDICAL CENTER

JL KAPTEN MUSLIM NO 43B

97374384

TEGUH SUHARTO,SE

PER/22/022016

RS.TRAUMA CENTRE

22/02/2016

31/12/2016

17

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

18

1500000001611

KLINIK MILLENIUM

JL KAPTEN MUSLIM NO 58C

63792195

SRI REZEKI SE

PER/27/022016

RS.TRAUMA CENTRE

01/03/2016

31/12/2016

19

1500000000197

KLINIK SENYUM JAYA ABADI

JL SETIABUDI NO 117 LINK V TG SARI

8219006

DRG ERITA FLORA MANURUNG

PER/28/022016

RS.TRAUMA CENTRE

26/02/2016

31/12/2016

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

20

1500000000191

RS ADVENT MEDAN

JL GATOT SUBROTO KM 4 MEDAN

4524875

YAYASAN RS ADVENT MEDAN

PER/16/022015

RS.TRAUMA CENTRE

26/02/2016

31/12/2016

21

1500000000190

RS BHAYANGKARA MEDAN

JL.KH WAHID HASYIM NO 1 MEDAN

8215990

POLDA SUMUT

PER/18/022015

RS.TRAUMA CENTRE

01/03/2016

31/12/2016

22

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

23

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

24

1500000000208

RS MARTHA FRISKA MULTATULI

JL MULTATULI KOMP MULTATULI INDAH NO 1

4149666

PT KARYA UTAMA SEHAT SEJAHTERA

PER/29/022016

RS.TRAUMA CENTRE

26/02/2016

31/12/2016

25

7-1446503984

RS SILOAM DHIRGA SURYA MEDAN

JL IMAM BONJOL NO 6 MEDAN

88881900

PT GRAMARI PRIMA NUSA

PER/15/012016

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

26

1500000000089

RSU BINA KASIH

JL JEND TB SIMATUPANG NO 148 SUNGGAL

8475111

YAYASAN BINA KASIH ABADI

PER/06/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

27

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

28

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

29

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

30

1500000000092

RSU SARI MUTIARA

JL KAPTEN MUSLIM NO 79 MEDAN

8451812

YAY SARI MUTIARA MEDAN

PER/08/122015

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

31

1500000000200

RSU VINA ESTETICA

JL SULTAN ISKANDAR MUDA NO 119

4147646

YAYASAN VINA ESTETICA

PER/30/022016

RS.TRAUMA CENTRE

01/03/2016

31/12/2016

MA11222I

20111


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12 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

32

KODE PROVIDER

7-1375319217

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

RUMAH SAKIT SETIABUDI

:

ALAMAT

JL MESJID NO 3 TANJUNG REJO MEDAN

KODE POS

IKS TELEPON

PIMPINAN NO IKS DR OTMAN SIREGAR SPOT

20122

PER/14/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

11/01/2016


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

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

3

1400000000527

KLINIK PANDU

JL. SM. RAJA NO. 627 PERDAGANGAN

ANTONIUS

PER/36/TC/0120 16

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

4

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

5

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

6

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

7

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

8

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

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

9

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

10

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

11

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

12

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

KANTOR CABANG

NO

KODE PROVIDER

:

B02- KANTOR CABANG KISARAN

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/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

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

3

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

4

1400000000109

KLINIK AMANAH

JL. SEI SILAU TIMUR KEC. BUNTU PANE

7352111

DR. NURHIMSYAH JUNEDI NASUTION

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

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

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

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

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

082368310 000

ZULKARNAEN

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

085261585 929

DRG ZANIYAR

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

085261585 929

DRG ZANIYAR

PER/30/12/2015

RS.TRAUMA CENTRE

01/12/2016

31/12/2016

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

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

13

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

14

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

15

1500000000663

PUSKESMAS KEDAI SIANAM

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

081361449 866

PUSKESMAS KEDAI SIANAM

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

1500000000665

PUSKESMAS LABUHAN RUKU

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

081362061 445

PUSKESMAS LABUHAN RUKU

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

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

6

1400000000609

KLINIK CENTRAL MEDIKA

7

1400000000607

KLINIK DEWI SARTIKA

8

1400000000728

KLINIK ESTOMIHI

9

1400000000714

KLINIK KESUMA BANGSA

10

1400000000714

KLINIK KESUMA BANGSA

11

1400000000727

12

MA11222I

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


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

18

1500000000676

PUSKESMAS LAUTADOR

KEC. LAUTADOR KAB. BATU BARA

PUSKESMAS LAUTADOR

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

19

1500000000666

PUSKESMAS LIMA PULUH

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

PUSKESMAS LIMA PULUH

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

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

21

1500000000668

PUSKESMAS PEMATANG PANJANG

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

081264704 44

PUSKESMAS PEMATANG PANJANG

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

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

23

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

24

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

25

1500000000672

PUSKESMAS SIMPANG DOLOK

DUSUN I DESA SIMPANG DOLOK KAB. BATU BARA

081361063 456

PUSKESMAS SIMPANG DOLOK

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000000673

PUSKESMAS TANJUNG TIRAM

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

081264222 800

PUSKESMAS TANJUNG TIRAM

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

27

1500000000674

PUSKESMAS UJUNG KUBU

JL. BESAR UJUNG KUBU DUSUN IV KAB. BATU BARA

081361006 865

PUSKESMAS UJUNG KUBU

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

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

29

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

MA11222I


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16 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

30

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

31

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

32

1500000000541

RSUD KABUPATEN BATU BARA

JL. DATUK KWALA GUNUNG KECAMATAN LIMA PULUH KABUPATEN BATU BARA

RSUD KABUPATEN BATU BARA

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

1

KODE PROVIDER

KODE PROVIDER

B03- KANTOR CABANG PADANG SIDEMPUAN

NAMA PROVIDER

PRAKTEK DOKTER SRI PRIHATIN K N HARAHAP

1400000000580

KANTOR CABANG

NO

:

:

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

JL LINTAS GUNUNGTUA-LANGGA PAYUNG DESA SIHOPUK BARU

DR SRI PRIHATIN K N HARAHAP

PER/08/022016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

26/02/2016


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

1400000000619

BPS KULON PROGO

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

7942321

DR. ARSYAD

PER/20/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

3

1400000000033

BPS KURNIA SEHAT

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

TAN ERFI

PER/14/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1400000000031

BPS MORAWA

JL. MEDAN-LUBUK PAKAM KM. 17

7942361

TAN ERFI

PER/16/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

5

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

6

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

7

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

8

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

9

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

10

1500000001880

KLINIK PRATAMA ESSIVA

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

7380666

DR. JHONES R. SIPAYUNG

PER/24/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

11

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

12

1400000000590

KLINIK PRATAMA MANNA

JL. PERTAHANAN NO. 98 PATUMBAK

DR. JHONI SINAGA

PER/21/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

13

1500000001879

KLINIK PRATAMA MARS

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

7952511

MARHEN, AMK

PER/25/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

14

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

15

7-1242107043

KLINIK PUJA

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

DR. BALBIR SINGH, MD

PER/30/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

MA11222I

20995

20351

20351

20585


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18 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

081265410 449

DR.DRG SUCI ERAWATI M.KES

PER/28/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

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

PUSKESMAS ARAS KABU

DESA ARAS KABU KEC. BERINGIN

082167926 514

PER/27/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

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

20

1400000000721

PUSKESMAS BANDAR DOLOK

DESA BANDAR DOLOK KEC. BANDAR DOLOK

081376670 815

PER/27/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

21

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

22

1400000000682

PUSKESMAS BANGUN PURBA

DESA BANGUN PURBA KEC. BANGUN PURBA

085262706 056

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

23

1400000000707

PUSKESMAS BATANG KUIS

BATANG KUIS KEC. BATANG KUIS

081265406 00

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

24

1400000000681

PUSKESMAS BIRU-BIRU

DESA BIRU-BIRU KEC. BIRU-BIRU

081262175 005

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

25

1400000000693

PUSKESMAS DALU SEPULUH

DESA DALU X KEC. BERINGIN

081376077 435

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

26

1400000000698

PUSKESMAS DELI TUA

DESA DELI TUA KEC. PATUMBAK

081264320 15

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

27

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

16

7-1239985383

KLINIK RAIHAN

MENTENG INDAH BLOK B1 NO. 29 MEDAN

17

1400000000032

KLINIK TUTUN SEHATI

18

1400000000706

19

MA11222I

20228


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

28

1400000000703

PUSKESMAS GUNUNG MERIAH

DESA GUNUNG MERIAH KEC. GUNUNG MERIAH

081397999 343

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

29

1400000000711

PUSKESMAS HAMPARAN PERAK

DESA HAMPARAN PERAK KEC. HAMPARAN PERAK

082160351 011

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

30

1400000000722

PUSKESMAS KARANG ANYER

DESA KARANG ANYER KEC. KARANG ANYER

081272118 888

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

31

1400000000720

PUSKESMAS KENANGAN

DESA KENANGAN KEC. PERCUT SEI TUAN

085358348 281

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

32

1400000000723

PUSKESMAS KOTA DATAR

DESA KOTA DATAR KEC. KOTA DATAR

082164747 266

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

33

1400000000726

PUSKESMAS KUTALIMBARU

DESA KUTALIMBARU KEC. KUTALIMBARU

081361326 400

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

34

1400000000710

PUSKESMAS LABUHAN DELI

DESA LABUHAN DELI KEC. LABUHAN DELI

081269230 222

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

35

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

36

1400000000697

PUSKESMAS MULIOREJO

DESA MULIOREJO KEC. SUNGGAL

081375333 643

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

37

1400000000699

PUSKESMAS NAMORAMBE

DESA NAMORAMBE KEC. NAMORAMBE

081264262 444

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

38

1400000000704

PUSKESMAS PAGAR JATI

DESA PAGAR JATI KEC. LUBUK PAKAM

081265884 10

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

39

1500000000029

PUSKESMAS PANCUR BATU

DESA PANCUR BATU KEC. PANCUR BATU

082168463 332

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

40

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

41

1400000000694

PUSKESMAS PATUMBAK

DESA PATUMBAK KEC. PATUMBAK

085275960 879

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

42

1500000000030

PUSKESMAS PEMATANG JOHAR

DESA PEMATANG JOHAR KEC.PEMATANG JOHAR

082160580 199

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

43

1500000000031

PUSKESMAS PETUMBUKAN

DESA PETUMBUKAN KEC. PETUMBUKAN

081264151 51

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

44

1400000000724

PUSKESMAS SEI MENCIRIM

DESA SEI MENCIRIM KEC. SUNGGAL

081370221 459

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

45

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

46

1400000000680

PUSKESMAS SIBOLANGIT

DESA SIBOLANGIT KEC. SIBOLANGIT

081264202 97

PER/27/01/2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

47

1400000000725

PUSKESMAS SUKARAYA

DESA SUKARAYA KEC. SUKARAYA

081265013 29

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

48

1400000000701

PUSKESMAS TALUN KENAS

DESA TALUN KENAS KEC. TALUN KENAS

081375190 502

PER/27/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

49

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

50

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

51

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

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7955114

DRS. JOHANNES S

PER/03/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

7945058

PT. MORAWA UTAMA

PER/12/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

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

RS SRI PAMELA

JL. JEND. SUDIRMAN NO. 299

24748

PT. SRI PAMELA MEDIKA NUSANTARA

PER/11/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

1400000000038

RSU DR.GL TOBING PTPN II

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

7944796

PTPN II (PERSERO)

PER/01/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

57

1400000000035

RSU HERNA

JL. BALAI KOTA NO. 2

21476

DR. DJOHAN ZEIN

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

58

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

59

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

60

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

61

1500000000099

RSU SEMBIRING DELI TUA

JL. BESAR NO. 77 DELI TUA

7030802

DRS. JOHANNES S

PER/08/012016

RS.TRAUMA CENTRE

07/01/2016

31/12/2016

62

1500000000248

RSUD DELI SERDANG

JL. THAMRIN LUBUK PAKAM

7952068

PEMKAB DELI SERDANG

PER/09/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

63

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

52

1400000000030

RS GRAND MEDISTRA

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

53

1500000001957

RS MORAWA UTAMA

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

54

1400000000589

RS PATAR ASIH

55

1500000001981

56

MA11222I

20351

20362


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22 / 108 02-03-2016 13:40:34


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/08/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1500000000053

KLINIK AZIZI

JL.TEMPULING NO.111 A MEDAN

DR.ANITAWATI

PER/05/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

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

4

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

5

1500000000231

KLINIK DANDY

JALAN RUMAH POTONG HEWAN NO.15 A

SITI HAWA MANAO

PER/01/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6

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

7

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

8

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

9

1500000000052

KLINIK HELVETIA III

JL.KL YOS SUDARSO SP.KANTOR

TEGUH SUHARTO

PER/06/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

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

11

1500000000459

KLINIK MUTIARA KOTA BANGUN

JL KL YOS SUDARSO KM 10.5

20241

NURHAYATI PURBA

PER/02/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

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

MA11222I

20241

66516974

20241

96333303


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

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

14

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

15

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

16

1400000000332

KLINIK TIMUR JAYA

JL.KL.YOS SUDARSO KM 10,6 MEDAN

DR.KURNIAWAN

PER/03/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

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

18

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

19

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

20

1400000000334

RUMAH SAKIT PELABUHAN BELAWAN

JL.STASIUN NO.92 BELAWAN

PT.PELABUHAN INDONESIA

PER/12/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1500000000067

MA11222I

:

6941927

B06- KANTOR CABANG BINJAI

NAMA PROVIDER

BPS SARANA

ALAMAT

JL BINJAI KM 11.7 NO 57 DESA PUJIMULYO SUNGGAL

KODE POS

IKS TELEPON

PIMPINAN NO IKS PER/01/012016


TIPE IKS RS.TRAUMA CENTRE

AWAL IKS 27/01/2016


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

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

10/02/2016

31/12/2016

3

7-1958581253

KLINIK UTAMA MENTARI

JL T AMIR HAMZAH KEL KWALA LANGKAT

20761

EMA PURNAMA

PER/02/022016

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

4

1500000000213

RS BANGKATAN PTPN II

JL SULTAN HASANUDDIN NO 40 BINJAI

PTPN II

PER/09/022016

RS.TRAUMA CENTRE

17/02/2016

31/12/2016

5

7-2048054644

RSU ARTHA MEDICA BINJAI

JL SAMANHUDI NO 22 BINJAI

20711

ARUSTA TARIGAN

PER/08/022016

RS.TRAUMA CENTRE

17/02/2016

31/12/2016

6

7-2030604103

RSU BIDADARI

JL. PERINTIS KEMERDEKAAN NO 147 BINJAI

20744

FIRMANSYAH SE MARS

PER05/022016

RS.TRAUMA CENTRE

16/02/2016

31/12/2016

7

7-2030604103

RSU BIDADARI

JL. PERINTIS KEMERDEKAAN NO 147 BINJAI

20744

FIRMANSYAH SE MARS

PER/05/022016

RS.TRAUMA CENTRE

16/02/2016

31/07/2017

8

7-2047722993

RSU LATERSIA

JL SOEKARNO HATTA NO 451

20731

ROBINSON SEMBIRING

PER/07/022016

RS.TRAUMA CENTRE

17/02/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

75080063

C00- KANTOR CABANG PADANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000040

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

2

1400000000039

RS TENTARA REKSODIWIRYO

JL DR WAHIDIN NO.1 PADANG

31003

DATASEMEN KESEHATAN

PER/45/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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3

KODE PROVIDER

RUMAH SAKIT KHUSUS BEDAH ROPANASURI

1500000000507

KANTOR CABANG

NO

NAMA PROVIDER

:

KODE PROVIDER

ALAMAT

JL. AUR NO. 8 PADANG

NAMA PROVIDER

ALAMAT

1400000000280

PRAKTEK DR SYAHRIL S

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

2

1400000000223

RSI IBNU SINA PAYAKUMBUH

JL PEMUDA NO 14 PAYAKUMBUH

3

1400000000239

RSI IBNU SINA SIMPANG AMPEK

4

1400000000239

5

1400000000063

NO

1

KODE PROVIDER

1500000000548

MA11222I

:

IKS TELEPON

PIMPINAN NO IKS

31938

DR. QUINTA SARI, SP. KK

PER/03/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/04/2016


C01- KANTOR CABANG BUKIT TINGGI

1

KANTOR CABANG

KODE POS

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR SYAHRIL S

PER/015/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

92222

YARSI SUMATERA BARAT

PER/013/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

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

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

C02- KANTOR CABANG SOLOK

NAMA PROVIDER

BALAI LATIHAN KERJA KABUPATEN SOLOK

ALAMAT

JL RAYA LUBUK SELASIH KM 01 KAYU ARO

KODE POS

IKS TELEPON

PIMPINAN NO IKS ZULFAKHRI,S.SOS

PER/18/122015



AWAL IKS 05/01/2016


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KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/07/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

DR.DINI ASTA DIANI

PER/14/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

NAGARI SUNGAI RUMBAI TIMUR KEC SUNGAI RUMBAI

YUSNIMAR SST

PER/12/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

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

1500000000948

KLINIK PRATAMA NURJINIS

JL BUKIT BERBUNGA NAGARI SUNGAI RUMBAI TIMUR

NURJINIS

PER/13/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

7

1500000000895

PUSKESMAS ALAHAN PANJANG

KEC LEMBAH GUMANTI KABUPATEN SOLOK

PER/16/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

8

1500000000547

RSUD AROSUKA KABUPATEN SOLOK

JL LINTAS SUMATERA AROSUKA KABUPATEN SOLOK

PER/10/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

9

1500000000464

RSUD SIJUNJUNG

JL LINTAS SUMATRA KM 110 TANAH BADANTUANG

20056

PER/08/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

10

1400000000017

RSUD SOLOK

SIMPANG RUMBIO KOTA SOLOK

20826

PER/09/122015

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

11

1500000000466

RSUD SUNGAI DAREH

JL LINTAS SUMATERA KM 2 PULAU PUNJUNG

40347

PER/11/122015

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

2

1400000000099

BLUD-RSUD SAWAHLUNTO

JL KARTINI NO 18

3

1500000000749

KLINIK ALTHAF

JL M YAMIN NO 83

4

1500000000722

KLINIK ARBA

5

1500000000761

6

KANTOR CABANG

MA11222I

:

74066837

DR.I.NYOMAN ARDANA PUTRA

RSUD SOLOK

D00- KANTOR CABANG PEKANBARU KOTA


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR. SITI ANDAN DEWI

PER/06/022016

RS.TRAUMA CENTRE

26/02/2016

31/12/2016

68401901

DR. YANTI FATMI, DK

PER/35/072015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

72026643

DR. IMAN RANDAL TARIGAN, SP.PD

PER/41/102015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28411

76892989

FEBRIAN CHASRA,SE.S.FILL

PER/37/072015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

KLINIK PRATAMA CENDANA HUSADA

JL. JATI NO. 76 SENAPELAN

28151

HJ. ELLIYANNORA

PER/46/112015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

8

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

9

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

10

7-300282953

RUMAH SAKIT ISLAM IBNU SINA

JL. MELATI NO. 60

0761 24242

PT. SYIFA UTAMA

PER/45/112015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001341

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

12

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

1

7-2146926741

KLINIK DR. ANDAN DEWI

JL. LINTAS TIMUR KM 34

28383

2

1500000001877

KLINIK FELLITA

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

28111

3

1500000001988

KLINIK FIDYA

JL. LINTAS TIMUR - PASAR SOREK SATU

4

1500000001878

KLINIK PELITA HATI

JALAN RAYA TALUK KUANTAN DESA LUBUK SAKAT PERHENTIAN RAJA

5

1500000001770

KLINIK PRATAMA BMC PEKANBARU

6

7-492772759

7

MA11222I

28122


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KODE PROVIDER

:

D02- KANTOR CABANG BATAM NAGOYA

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

BATAMINDO INDUSTRIAL PARK KLINIK

PER/59/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

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

3

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

4

1400000000595

BP HARAPAN KITA BATU AJI

RUKO CENTRAL MUKA KUNING BLOK A NO.8 BATU AJI

29438

077836147 5

PT AUDY JAYA PRATAMA

PER/47/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2015

5

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

6

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

7

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

8

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

9

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

10

1400000000072

KLINIK MEDIKA

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

29425

082389094 888

DR KRISMADIES, M.KKK

PER/53/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1400000000466

KLINIK NAYAKA HUSADA 03 KABIL

RUSUNAWA BPJS KETENAGAKERJAAN KABIL

29467

711448

PT NAYAKA ERA HUSADA

PER/64/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

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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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

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

14

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

15

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

16

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

17

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

18

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

19

0700000000015

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

20

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

KANTOR CABANG

NO

1

KODE PROVIDER

1500000000239

MA11222I

:

D03- KANTOR CABANG DUMAI

NAMA PROVIDER

BP AMANAH

ALAMAT

JL SOEKARNO HATTA KM 14 BAGAN BESAR

KODE POS

28882

IKS TELEPON

PIMPINAN NO IKS DR. DEVY DIANNY

PER/45/122015



AWAL IKS 01/01/2016


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1400000000024

KLINIK RAWAT INAP TUNAS MUDA MEDIKA

JL WAN DAHLAN IBRAHIM NO 8 DUMAI

28811

439026

DR RAHMI SALBI

PER/47/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

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

4

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

5

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

6

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

7

1400000000492

RS CAHAYA

JL LINTAS RIAU UJUNG TANJUNG

28983

66818300

DRG CAHAYA PURNAMA SARI

PER/49/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1300000000020

RSUD DUMAI

JL TANJUNG JATI NO 4

38367

PEMKO DUMAI

PER/50/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

D05- KANTOR CABANG DURI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-1704752493

KLINIK PRATAMA BERKAH

JALAN LINTAS DURI – PEKANBARU DESA PINGGIR

28784

AFRIZAL TANJUNG

7-1704752493

RS.TRAUMA CENTRE

17/02/2016

31/12/2016

2

7-1704752493

KLINIK PRATAMA BERKAH

JALAN LINTAS DURI – PEKANBARU DESA PINGGIR

28784

AFRIZAL TANJUNG

7-1704752493

RS.TRAUMA CENTRE

02/02/2016

31/12/2016

MA11222I


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:

KODE PROVIDER

D07- KANTOR CABANG BATAM SEKUPANG

NAMA PROVIDER

ALAMAT

1

1400000000574

KLINIK DUNIA MEDICAL CENTRE

RUKO FANINDO BLOK B NO 7-10 TJ UNCANG, BATU AJI-BATAM

2

7-1265428985

KLINIK GLOBAL MEDICAL CENTRE

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

3

1400000000255

KLINIK VELY

KOMPLEK RUKO FANINDO BLOK A NO 12 A KEL TANJUNG UNCANG

4

1400000000132

KLINIK YAHYA MEDICAL CENTER

RUKO SAGULUNG PERMAI BLOK B NO 14-15 BATU AJI

KANTOR CABANG

NO

:

KODE PROVIDER

KODE POS

29428

29422

IKS TELEPON

NO IKS

AKHIR IKS

DR KON SAN

PER/04/022016

RS.TRAUMA CENTRE

26/02/2016

31/01/2017

077835829 23

RIRIS LIANI

PER/02/012016

RS.TRAUMA CENTRE

05/01/2016

03/01/2017

9131737

DR. SITI VERA NOTARINA

PER/01/01/2016

RS.TRAUMA CENTRE

05/01/2016

03/02/2017

392748

SYARIEF A. FAHMI, ST

PER/03/012016

RS.TRAUMA CENTRE

05/01/2016

03/01/2017

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

1400000000559

RS BHAYANGKARA JAMBI

JL RADEN MATTAHER NO 03

23246

2

0700000000017

RS DR BRATANATA

JL RD MATTAHER NO 33

20388

3

1400000000560

RS ROYAL PRIMA JAMBI

JL RADEN WIJAYA RT 35 KEBON KOPI

MA11222I

AWAL IKS

E00- KANTOR CABANG JAMBI

NAMA PROVIDER

:

TIPE IKS

3581242

1

KANTOR CABANG

PIMPINAN

RS DR BRATANATA

TIPE IKS

AWAL IKS

AKHIR IKS

PER / 03 / 012016

RS.TRAUMA CENTRE

20/01/2016

30/11/2016

PER / 02 / 012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

PER / 01 / 012016

RS.TRAUMA CENTRE

20/01/2016

30/11/2016

E01- KANTOR CABANG MUARO BUNGO


SM0480



32 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

1500000000297

RSU MAYJEN H.A THALIB (TC)

JL JEND BASUKI RAHMAT NO 1 SUNGAI PENUH - PROP JAMBI

2

1400000000053

RSUD CHATIB QUZWAIN SAROLANGUN

JL. LINTAS SUMATERA KM.09 DESA BUKIT,SAROLANGUN

KANTOR CABANG

NO

:

KODE PROVIDER

KODE POS

IKS TELEPON

PIMPINAN NO IKS

21447

TIPE IKS

AWAL IKS

AKHIR IKS

PEMDA KERINCI

PER/08/102015

RS.TRAUMA CENTRE

27/01/2016

30/09/2016

DR IRWAN MISWAR

PER/01/032016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

G00- KANTOR CABANG PALEMBANG

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

3

1500000001101

UPTD BLK INDUSTRI DISNAKERTRANS

JL. RESIDEN H AMALUDDIN SAKO KENTEN

PER/02/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

G02- KANTOR CABANG PANGKAL PINANG

NAMA PROVIDER

ALAMAT

1

1400000000730

BPRB MEDIKA STANNIA

BELINYU

2

1500000000133

KLINIK BAKTI TIMAH PARIT TIGA

JL. RAYA PARIT TIGA

MA11222I

KODE POS

IKS TELEPON

PIMPINAN NO IKS

351143

TIPE IKS

AWAL IKS

AKHIR IKS

YAYASAN BAKTI TIMAH

PER/001/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

YAYASAN BAKTI TIMAH

PER/002/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

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

4

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

5

1500000000132

RS BAKTI TIMAH MUNTOK

JL. RAYA TIMAH KOMPLEK PUSMET MUNTOK

21008

YAYASAN BAKTI TIMAH

PER/002/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

6

1400000000729

RUMAH SAKIT MEDIKA STANNIA

JL. JEND. SUDIRMAN NO. 03 SUNGAILIAT

95837

YAYASAN BAKTI TIMAH

PER/001/122015

RS.TRAUMA CENTRE

29/01/2016

29/02/2016

KANTOR CABANG

NO

:

KODE PROVIDER

G03- KANTOR CABANG MUARA ENIM

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001268

BALAI LATIHAN KERJA KAB.MUARA ENIM

JALAN PETROSIA III MUARA ENIM

KAB MUARA ENIM

PER/01/012016

RS.TRAUMA CENTRE

28/01/2016

28/01/2017

2

1500000001268

BALAI LATIHAN KERJA KAB.MUARA ENIM

JALAN PETROSIA III MUARA ENIM

KAB MUARA ENIM

PER/01/012016

RS.TRAUMA CENTRE

08/05/2016

28/01/2017

3

1500000001202

BALAI LATIHAN KERJA KOTA PRABUMULIH

JL JEND SUDIRMAN KM 35

KOTA PRABUMULIH

PER/42/062015

RS.TRAUMA CENTRE

28/01/2016

28/01/2017

KANTOR CABANG

MA11222I

:

320618

H00- KANTOR CABANG BANDAR LAMPUNG


SM0480



34 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

3

1400000000504

KLINIK KOSASIH PALAPA

JL. CUT NYAK DIEN NO. 62 PALAPA BANDAR LAMPUNG

35116

7140218


PER/26/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

4

1400000000507

KLINIK KOSASIH PANJANG

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

9761738


PER/28/112015

RS.TRAUMA CENTRE

04/01/2016

30/11/2016

5

1400000000498

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

MA11222I


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35 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

13

1500000000181

RS GLADISH MEDICAL CENTER

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

14

1500000000253

RS MUHAMMADIYAH METRO

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

15

1500000000209

RS NATAR MEDIKA

16

1500000000218

17

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

CV GLADISH MEDICAL CENTER

PER/04/022016

RS.TRAUMA CENTRE

10/02/2016

31/01/2017

7008000

PERSYARIKATAN MUHAMMADIYAH

PER/09/022016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

JL. RAYA NATAR NOMOR 4 MUARA PUTIH

92521

YAYASAN ABDI KARYA

PER/05/022016

RS.TRAUMA CENTRE

10/02/2016

31/01/2017

RS TINGKAT IV 02.07.04 (RS DKT) BANDAR LAMPUNG

JL. KAPT. A RIVAI 7 PENENGAHAN TANJUNG KARANG PUSAT

770430

PER/08/022016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

1400000000116

RS URIP SUMOHARJO

JL URIP SUMOHARJO NO 200 SUKARAME

771322

PT GUNUNG SULAH MEDIKA

PER/07/022016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

18

1500000000115

RS WISMA RINI

JL. WISMA RINI NO. 01 PRINGSEWU

21582

YAYASAN BUDI SETIA BHAKTI

PER/01/022016

RS.TRAUMA CENTRE

10/02/2016

31/01/2017

19

1500000000165

RSUD DR. H. ABDUL MOELOEK PROVINSI LAMPUNG

JALAN DR. RIVAI NOMOR 06 PENENGAHAN

703312

PROVINSI LAMPUNG

PER/05/012015

RS.TRAUMA CENTRE

10/02/2016

31/01/2017

20

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

21

1500000000134

RSUD PESAWARAN

JL. RAYA KEDONDONG DESA WAY LAYAP KEC. GEDONG TATAAN

KABUPATEN PESAWARAN

PER/03/012015

RS.TRAUMA CENTRE

10/02/2016

31/01/2016

22

1500000000134

RSUD PESAWARAN


KABUPATEN PESAWARAN

PER/02/022016

RS.TRAUMA CENTRE

16/02/2016

31/01/2017

23

1500000000134

RSUD PESAWARAN


KABUPATEN PESAWARAN

PER/02/022016

RS.TRAUMA CENTRE

10/02/2016

31/01/2017

24

1500000000427

UPTD BALAI LATIHAN KERJA BANDAR LAMPUNG

JL. PAGAR ALAM NOMOR 127 BANDAR LAMPUNG

DINAS TENAGA KERJA DAN TRANSMIGRASI PROVINSI LAMPUNG

PER/06/022016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

MA11222I


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NO

1

KODE PROVIDER

H01- KANTOR CABANG LAMPUNG TENGAH

NAMA PROVIDER

RS YUKUM MEDICAL CENTRE

7-1568007187

KANTOR CABANG

NO

:

:

KODE PROVIDER

ALAMAT

JL. NEGARA NO. 99 KM 67 YUKUM JAYA KEC. TERBANGGI BESAR

KODE POS

34163

IKS TELEPON

PIMPINAN NO IKS

072525333

PT. MITRA MEDICAL CENTER

PER/002/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

22/02/2016


J00- KANTOR CABANG JAKARTA SALEMBA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

1400000000351

RSIA EVASARI

JL. RAWAMANGUN NO. 27 PRAMUKA JAKARTA PUSAT 10570

4202851

PER/02/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

KANTOR CABANG

NO

1

:

KODE PROVIDER

NAMA PROVIDER

RUMAH SAKIT SATYA NEGARA

7-2307624884

KANTOR CABANG

MA11222I

J03- KANTOR CABANG JAKARTA KELAPA GADING

:

ALAMAT

JALAN AGUNG UTARA RAYA BLOK A NO.1 JAKARTA UTARA

KODE POS

14350

IKS TELEPON

PIMPINAN NO IKS

64715200

DR. SANTOSO KURNIAWAN

PER/06/062015


AWAL IKS 29/02/2016


J04- KANTOR CABANG JAKARTA RAWAMANGUN


SM0480



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Periode : 01012016 s/d 31122016

NO

1

KODE PROVIDER

7-1669163483

KANTOR CABANG

NO

1

1

1

:

KLINIK ARAS

:

KODE PROVIDER

KODE PROVIDER

1500000000145

MA11222I

RS PELNI

:

JL. PULOMAS BARAT VI NO.20, JAKARTA TIMUR

KODE POS

13210

IKS TELEPON

PIMPINAN NO IKS

2977 9999

DR MARIA

PER/01/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/02/2016


ALAMAT

KODE POS

JL SRENGSENG SAWAH RT 001/009 JAGAKARSA

IKS TELEPON

PIMPINAN NO IKS

7869916

DR. SERI ANNI NASUTION

PER/01/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/01/2016


J0P- KANTOR CABANG JAKARTA SLIPI

NAMA PROVIDER

1400000000303

ALAMAT

J06- KANTOR CABANG JAKARTA CILANDAK

NAMA PROVIDER

1500000000170

KANTOR CABANG

NO

RSTC OMNI PULOMAS

KODE PROVIDER

KANTOR CABANG

NO

NAMA PROVIDER

ALAMAT

JL AIPDA KS TUBUN 92-94

KODE POS

10210

IKS TELEPON

PIMPINAN NO IKS

5485870

PT PELNI

PER/09/092015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

27/01/2016


J11- KANTOR CABANG TANGERANG BATUCEPER

NAMA PROVIDER

KLINIK PRATAMA MH THAMRIN CENGKARENG

ALAMAT

JL DAAN MOGOT KM 17 NO 69 RT02/04 KLDRS

KODE POS

IKS TELEPON




AWAL IKS 01/02/2016


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

2

7-1459450363

RS HERMINA DAAN MOGOT

JL KINTAMANI RAYA NO 2 DAAN MOGOT BARU

3

1500000000146

RS KARANG TENGAH MEDIKA

JL KARYAWAN IV CILEDUG KARANG TENGAH

KANTOR CABANG

NO

1

KODE PROVIDER

KODE PROVIDER

RS HARAPAN JAYAKARTA

:

ALAMAT

JL BEKASI TIMUR RAYA NO.6 KM 18 PULOGADUNG

PIMPINAN NO IKS DR I ICHSAN HANAFI MARS

11710

7336699

TIPE IKS

AWAL IKS

AKHIR IKS

PER/004/012016

RS.TRAUMA CENTRE

22/01/2016

17/01/2017

PER/005/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

KODE POS

13210

IKS TELEPON

PIMPINAN NO IKS

46822879

DR. SRI HARTATI

PER/TC/01/0120 16

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

11/01/2016


K00- KANTOR CABANG BANDUNG SUCI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7271451

NENDEN SUHARTINI

PER/01/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

JL. CIHAMPELAS 7 BANDUNG

4201596

PT KIMIA FARMA (PERSERO) TBK

PER/09/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

KLINIK KIMIA FARMA 51

JL.IR.H.JUANDA 69 BANDUNG

4203331


PER/11/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

KLINIK KIMIA FARMA SETIABUDI

JL.SETIABUDI 36 BANDUNG

2038048


PER/12/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

1

1500000001896

BIOFIT HEALTH CENTER

JL. WR SUPRATMAN NO. 69, BANDUNG

2

1500000000837


3

1500000000834

4

1500000000835

MA11222I

IKS TELEPON

J12- KANTOR CABANG JAKARTA PULOGADUNG

NAMA PROVIDER

7-1362178499

KANTOR CABANG

NO

:

KODE POS

40114


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

5

1500000000836

KLINIK KIMIA FARMA SINDANGLAYA

JL. SUKAMISKIN 126B BANDUNG

7178664


PER/13/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

6

1500000000859

KLINIK ALIVIA MEDIKA

JL. PASUNDAN NO. 107, BANDUNG

87805328

YUDI PRIHARTANTO

PER/02/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

7

1500000000860

KLINIK AMANAH

JL. PHH MUSTOFA NO. 124, BANDUNG.

7279705

YUDI PRIHARTANTO

PER/03/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

8

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

9

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

10

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

11

1500000000585

KLINIK ITENAS

JALAN PHH MUSTOFA NO. 23 , BANDUNG

PT. RS PADJADJARAN

PER/07/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

12

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

13

1500000000833


JL. BUAH BATU 59 BANDUNG

7305019


PER/10/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

14

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

15

1500000000704

KLINIK PRATAMA SEHATI

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

16

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

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

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

18

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

19

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

20

1500000000801

RS MATA CICENDO

JL. CICENDO NO. 4 BANDUNG

4231280

KEMENKES

PER/20/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

21

1100000000014

RS PINDAD

JL. GATOT SUBROTO NO.517 PAPANGGUNGAN BANDUNG

7322468

PER/21/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

22

1100000000015

RS SARININGSIH

JL. LL RE MARTADINATA NO. 9

PER/22/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

23

1500000001399

RS. SALAMUN

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

24

1500000001934

RSKB HALMAHERA SIAGA

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

25

1500000000697

RSU BUNGSU

JL. VETERAN NO. 6, BANDUNG

26

7-2299406693

RSU HERMINA ARCAMANIK

JL. A H NASUTION NO. 50 BANDUNG, JAWA BARAT, 40291

27

1500000000460

RSUD KOTA BANDUNG

JL. RUMAH SAKIT NO. 22, UJUNGBERUNG

28

1500000001936

RSUP HASAN SADIKIN BANDUNG

JL. RAYA PASTEUR NO 36, BANDUNG

MA11222I

40115

40291

2032090

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

PER/23/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

4206061

PROF DR M AHMAD DJOJOSUGITO, DR, SP OT

PER/24/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

4231550

DR. LILIAN MELATTIE E. NORE

PER/25/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

87242525

DR. TOMMY JOESOEF

PER/25/012016

RS.TRAUMA CENTRE

01/03/2016

31/12/2016

PER/26/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

PER/27/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

7811794

40161

2034953

KEMENKES


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NO

KODE PROVIDER

:

K01- KANTOR CABANG BEKASI KOTA

NAMA PROVIDER

ALAMAT

1

1500000000698

KLINIIK TC ANNISA

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

2

1500000000830

KLINIK TC CAHAYA ASYPA

TAMAN NAROGONG INDAH BLOK C.18 NO 1

3

1500000000699

KLINIK TC HANDAYANI MEDIKA

4

1500000000744

5

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/17/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

PER/24/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

JL RAYA KALIMALANG NO 9 DS CIBUNTU CIBITUNG BEKASI

PER/18/052015

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

04/01/2016

31/12/2016

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

6

1500000001328

KLINIK TC SETO HASBADI 01

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

PER/30A/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

7

1500000001327


JL RAYA SULTAN AGUNG BLOK O NO 27 MEDAN SATRIA

PER/30B/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

8

1500000001326


JL RAYA IMAM BONJOL NO 01 TELAGA ASIH CIKARANG BARAT

PER/30C/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

9

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

10

1400000000121

RSTC CIBITUNG MEDIKA

J LRAYA BOSIH NO.117 CIBITUNG

88323444

PT ADHI PUTRA MEDIKA

PER/01/012016

RS.TRAUMA CENTRE

09/02/2016

31/12/2016

11

1400000000121

RSTC CIBITUNG MEDIKA

J LRAYA BOSIH NO.117 CIBITUNG

88323444

PT ADHI PUTRA MEDIKA

PER/19/052015

RS.TRAUMA CENTRE

04/01/2016

31/12/2015

12

1100000000020

RSTC HOSANA MEDICA

JL PRAMUKA NO.12 RAWA LUMBU NAROGONG

8221570

JOHANES POSO

PER/27/062015

RS.TRAUMA CENTRE

04/01/2016

31/12/2015

MA11222I

ALAN


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Periode : 01012016 s/d 31122016

NO

13

KODE PROVIDER

1100000000020

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

RSTC HOSANA MEDICA

:

ALAMAT

KODE POS

JL PRAMUKA NO.12 RAWA LUMBU NAROGONG

IKS TELEPON

PIMPINAN NO IKS

8221570

JOHANES POSO

PER/02/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

09/02/2016


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/16/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

2

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

3

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

4

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

5

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

6

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

7

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

8

1500000001536

PUSKESMAS JASINGA

JL.LET.SAYUTI JASINGA

PER/21/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

MA11222I

16810

87952811 085780041 002


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

9

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

10

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

11

1200000000006

RS BINA HUSADA TC

JL MAYOR OKING JAYAATMAJA

87911000

DR HARSONO

PER/01/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

12

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

13

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

14

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

15

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

16

1500000000074

RS PMI BOGOR TC

JL PAJAJARAN NO 80

YAYASAN PMI

PER/13/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

17

1400000000309

RS SALAK BOGOR

JL JENDRAL SUDIRMAN NO 8

8344609

KESDAM SILIWANGI

PER/03/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

18

1500000000072

RS SENTRA MEDIKA CIBINONG TC

JL MAYOR OKING JAYAATMAJA

87909999

DRG HERMAN

PER/11/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

19

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

20

1500000000637

RS VANIA

JL SILIWANGI NO 11 KEL SUKASARI BOGOR TIMUR

PER/19/012016

RS.TRAUMA CENTRE

25/01/2016

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

21

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

22

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

23

1500000001535

RSUD CIAWI BOGOR

JL.RAYA PUNCAK NO.479 CIAWI

PER/20/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

24

1400000000442

RSUD KOTA BOGOR

JALAN RAYA SUMERU NO 120

DR TRIWANDHA ELAN

PER/08/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

25

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

26

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

KANTOR CABANG

NO

KODE PROVIDER

:

081211012 84

K04- KANTOR CABANG TANGERANG CIKOKOL

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

3

1400000000652

RS. SARI ASIH CILEDUG

JL HOS COKROAMINOTO NO 38 CILEDUG

7333430

PT. SARI ASIH PUTRA MANDIRI, DICKY R H PAMUNGKAS

PER/66/122015

RS.TRAUMA CENTRE

01/01/2016

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

4

1400000000651

RS. SARI ASIH KARAWACI

JL. IMAM BONJOL NO.38

5522794

PT. SARI ASIH PUTRA MANDIRI, DICKY R H PAMUNGKAS

PER/65/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

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

6

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

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

WAWAN MULYANA

PER/07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

085254259 386

DRG. DIAN KIBLATI

PER/078/062015

RS.TRAUMA CENTRE

01/05/2016

31/05/2016

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

KLINIK MEDIKA

JL JEND AHAMD YANI NO.56

209975

DR. DIANAHAN

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

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

1

1500000000330

BP PERMATA HUSADA

JL LETJEND SUPRAPTO NO 45 CILEGON

2

1500000001467

KLINIK DJASARI MEDIKA CURUG

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

3

1500000000331

KLINIK ISNA MEDIKA

4

1500000000254

5

6

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

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

8

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

9

1400000000082

RSUD BANTEN

JL SYECH NAWAWI AL-BANTANI

8490911

PROVINSI BANTEN

PER/010/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

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

11

1400000000320

RSUD SERANG

JL RUMAH SAKIT NO.1

200528

KOTA SERANG

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

:

KODE PROVIDER

42111

K06- KANTOR CABANG SUKABUMI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000059

RS BETHA MEDIKA

JL. RAYA CISAAT NO. 595

224128

PER/14/TC/12/20 15

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1400000000671

RSUD CIMACAN

JL. RAYA CIMACAN NO. 17 CIPANAS

512465

PER/15/TC/1220 15

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

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

KANTOR CABANG

MA11222I

:

K07- KANTOR CABANG TASIKMALAYA


SM0480



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NO

1

KODE PROVIDER

RUMAH SAKIT JASA KARTINI

1400000000593

KANTOR CABANG

NO

NAMA PROVIDER

:

KODE PROVIDER

ALAMAT

JL OTTO ISKANDARDINATA NO. 15

NAMA PROVIDER

ALAMAT

1300000000035

RS. MH THAMRIN PURWAKARTA

JL. RAYA BUNGURSARI NO. 36 SADANG

2

1400000000434

RSUD BAYU ASIH

JL VETERAN NO 39

NO

KODE PROVIDER

:

IKS TELEPON

PIMPINAN NO IKS

331808

PT. KARSA ABDI HUSADA

PER/68/122015

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

09/02/2016


K09- KANTOR CABANG PURWAKARTA

1

KANTOR CABANG

KODE POS

KODE POS

IKS TELEPON

PIMPINAN NO IKS

8222222

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

TIPE IKS

AWAL IKS

AKHIR IKS

PER/01/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

PER/20/102015

RS.TRAUMA CENTRE

21/01/2016

31/10/2016

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

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

3

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

4

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

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

1500000001948

KLINIK SATRIA MEKAR

JL PANGKALAN LOJI DESA TAMAN MEKAR KEC. PANGKALAN

085624943 888

YAYAT SALEH

PER/25/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

14

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

15

1500000001714

KLINIK YASMIN

JL IR H JUANDA KM2 KOTA BARU RT 02/05

SAFRINA DEWI

PER/23/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

16

1500000000849

LIRA MEDIKA

JL SYECH QURO NO 14 PALUMBONSARI

NY ANGELIAQUE ARYANTO

PER/09/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

MA11222I

41311

41311

8452555


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

17

7-1272337870

RS BAYU KARTA

JL. KERTABUMI NO 44 KARAWANG

41311

18

7-1122449393

RS CITO

JL. ARTERI TOL KARAWANG BARAT

41312

19

1400000000368

RS CITRA SARI HUSADA

JL RAYA KOSAMBI TELAGASARI KM 3 KLARI

20

1500000001708

RS DELIMA ASIH SISMA MEDIKA

JL WIRASABA NO 54 JOHAR KEC KARAWANG TIMUR

21

1400000000349

RS ISLAM KARAWANG

JL. PANGKAL PERJUANGAN KM. 2

22

1500000000408

RS IZZA

JL RAYA CISELANG DESA CIKAMPEK UTARA KECAMATAN KOTA BARU

23

1400000000348

RS KARYA HUSADA

JL. JEND. AHMAD YANI NO. 98 CIKAMPEK KARAWANG

24

1400000000347

RS PURI ASIH JATISARI

JL. RAYA JATISARI NO. 3 MEKARSARI JATISARI

25

7-2322882543

RS ROSELA

JL. INTERCHANGE NO 3 TOL KARAWANG BARAT DS WADAS

26

06823

RSU DELIMA ASIH SISMA MEDIKA

JL WIRASABA NO 54 JOHAR

27

7-1277095197

RUMAH SAKIT FIKRI MEDIKA

JL. RAYA KOSAMBI TELAGASARI KM 3

KANTOR CABANG

MA11222I

:

41311

IKS TELEPON

PIMPINAN NO IKS

026740181 8

AWAL IKS

AKHIR IKS

DR WHISNU SANTOSO

PER/01/012016

RS.TRAUMA CENTRE

06/01/2016

31/12/2016

HAJI GANGGA ENDANG

PER/03/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

437507

ADE RELAWATI

PER/05/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

403073

PT DELIMA SISMA MEDIKA

PER/04/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

PER/06/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

PER/07/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

PER/08/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

DR AKID

PER/10/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

DR YESI KARYA LIANTI, MARS

PER/26/032015

RS.TRAUMA CENTRE

01/03/2016

31/12/2016

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PER/02/012015

RS.TRAUMA CENTRE

05/01/2016

30/06/2016

8386830

41311

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

403073

41314

TIPE IKS

H SAEPUDIN

K13- KANTOR CABANG TANGERANG CIKUPA


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

KANTOR CABANG

MA11222I

:

K14- KANTOR CABANG BEKASI CIKARANG


SM0480



51 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

1400000000549

KLINIK GRAHA BINA HUSADA

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

2

7-1254255963

KLINIK KASIH ANUGERAH SERANG BARU

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

3

7-1251921754

RS AMANDA

4

7-1432249443

5

6

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

PT.GRAHA BINA HUSADA

PER/54/122015

RS.TRAUMA CENTRE

05/01/2016

30/11/2016

17530

DR KETTLER SIAHAAN, MBA

PER/58/122015

RS.TRAUMA CENTRE

04/01/2016

04/11/2016

JALAN RAYA SERANG , NO. 83 CIKARANG

17530

DR.HAMIDAH, M.KES

PER/60/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

RS ANNISA CIKARANG

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

17530

DR.NOOR ARIDA SOFIANA, MBA

PER/55/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

7-1254255965

RS DR SANDER.B

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

17340

DR. HASAN

PER/59/122015

RS.TRAUMA CENTRE

05/01/2016

30/11/2016

7-1250333673

RS HOSANA LIPPO CIKARANG

JL UTAMA BIIE ,NO. 01, LIPPO CIKARANG BEKASI

17530

JOHANNES POSO

PER/56/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

KANTOR CABANG

NO

KODE POS

KODE PROVIDER

:

89836243

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/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

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

3

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

MA11222I


SM0480



52 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

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

5

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

6

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

7

1400000000251

KLINIK NAYAKA HUSADA 04

JL TERUSAN KOPO KM 12 KATAPANG KAB. BANDUNG

40921

61804614

PT. NAYAKA ERA HUSADA

PER/08/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

MA11222I


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

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

17

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

18

1500000001388

SANTOSA HOSPITAL BANDUNG KOPO

KH. WAHID HASYIM NO 461- 463 KOPO BANDUNG

40221

54280555

PT SANBE PRAKARSA HUSADA

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/04/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

2

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

3

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

4

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

5

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

6

1500000001690

KLINIK EKA MEDIKA

JL RAYA NAROGONG NO 116 KLAPANUNGGAL

16820

DR HARUMITI RAMIL,MKK

PER/11/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

MA11222I

29289475


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

7

1500000001687

KLINIK GRACIA

JL RAYA NAROGONG KM 17 DESA CILEUNGSI

8

1500000001331

KLINIK MH THAMRIN MEKARSARI

RUKO EBONY BLOK 23 RT 006/004 DESA CILEUNGSI

9

1500000001383

KLINIK PKO MUHAMMADIYAH

PERUM PTSC JL ANGGREK BLOK A NO 12 KEC CILEUNGSI

10

1500000001691

RS HERMINA MEKARSARI

JL RAYA CILEUNGSI JONGGOL KM 1

16820

11

1500000001927

RS PERMATA JONGGOL

JL RAYA JONGGOL NO 1 A SUKAMANAH JONGGOL

16120

12

1400000000327

RSTC MH THAMRIN CILEUNGSI

JL RAYA NAROGONG KM 16 LIMUSNUNGGAL CILEUNGSI

KANTOR CABANG

NO

KODE PROVIDER

:

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

SURYATI SARI ARUM, SKOM

PER/10/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

DR RISKA ARISKA YULIANTI

PER/06/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

DR NUR CAHYANINGSIH

PER/07/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

29232525

VIVI FRIYATNI, SKM

PER/01/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

89931333

DR EVY FEBRINA NURPENI, MARS

PER/03/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

8235052

DR ABDUL RADJAK

PER/02/012016

RS.TRAUMA CENTRE

21/01/2016

31/12/2016

16820

8235052

K17- KANTOR CABANG TANGERANG CIMONE

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000649

RS DINDA

GALUH NO 2 JATIUWUNG

15133

PT DINDA MEDISTRA

PER/04/042016

RS.TRAUMA CENTRE

26/01/2016

31/12/2016

2

1500000000649

RS DINDA

GALUH NO 2 JATIUWUNG

15133

PT DINDA MEDISTRA

PER/04/012016

RS.TRAUMA CENTRE

26/01/2016

31/12/2016

3

1100000000004

RSU AN NISA

JL GATOT SUBROTO NO 96 KM 3, CIBODAS

DR EDIANSYAH, MARS

PER/05/2016

RS.TRAUMA CENTRE

27/01/2016

31/12/2016

MA11222I

5525564


SM0480



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Periode : 01012016 s/d 31122016

NO

4

KODE PROVIDER

1100000000005

KANTOR CABANG

NO

NAMA PROVIDER

KODE PROVIDER

RSU ARIYA MEDIKA

:

ALAMAT

KODE POS

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

IKS TELEPON

PIMPINAN NO IKS

5902226

DR E TRISNO SUSILO

PER/06/022016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

12/02/2016


K18- KANTOR CABANG DEPOK

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000001929

KLINIK BHAKTI JAYA

JL. KARTINI - CITAYAM RAYA NO.18 A

16411

77203062

DRG.SRI SULISWATI,MM

PER/32/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1500000001808

KLINIK IRENK MEDIKA

JL BAHAGIA RAYA NO 18 DEPOK TIMUR

16413

7715039

ARUJI AMBAR SUKOCO, SE

PER/31/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1500000001922

KLINIK YANI MEDIKA

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

4

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

5

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

6

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

7

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

8

1500000001916

RS PERMATA DEPOK

JL RAYA MUCHTAR NO.22 SAWANGAN DEPOK

29669000

PT MUFIDAH MEDIKA SAWANGAN

PER/29/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

MA11222I

16511


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

9

1400000000181

RS SENTRA MEDIKA CISALAK

JL RAYA JAKARTA BOGOR KM 33 CISALAK DEPOK

10

1400000000182

RS SIMPANGAN DEPOK

JL RAYA JAKARTA BOGOR KM 36 SUKAMAJU DEPOK

11

1400000000180

RS TUGU IBU

JL RAYA JAKARTA BOGOR KM 29 CIMANGGIS DEPOK

12

1400000000285

RSTC GRHA PERMATA IBU

JL KH USMAN NO 168 BEJI KUKUSAN DEPOK

KANTOR CABANG

NO

1

KODE PROVIDER

KODE PROVIDER

RS OMNI ALAM SUTERA

:

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR HERMAN WIDYATOMO

PER/22/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

D WARSITO

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8710870

H MARIS RINALDI

PER/23/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7778899

DR PARAMITA

PER/25/122015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

8743790

ALAMAT

JL ALAM SUTERA BOULEVARD KAV 25 SERPONG

KODE POS

15325

IKS TELEPON

PIMPINAN NO IKS

53125555

PT SARANA MEDITAMA INTERNATIONAL

PER/01/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/02/2016


L00- KANTOR CABANG SEMARANG PEMUDA

NAMA PROVIDER

ALAMAT

KODE POS

1

7-1435412603

PUSKESMAS BRATI

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

58153

2

7-1435686266

PUSKESMAS GABUS I

JL. TAMAN SARI DS. SULUSARI, KEC. GABUS

58183

MA11222I

IKS TELEPON

K19- KANTOR CABANG TANGERANG BSD

NAMA PROVIDER

7-1679975283

KANTOR CABANG

NO

:

KODE POS

IKS TELEPON

PIMPINAN NO IKS

085290455 655

TIPE IKS

AWAL IKS

AKHIR IKS

MURSIYATI, SKM

PER/22-1/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

SOEPARNO, SKM

PER/22-2/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

TOTOK EKO SUBANDRIYO, SKM

PER/22-3/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

DR. AGUNG PROBO M, M.SI

PER/22-4/112015

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

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

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

58164

029251353 488

DR. SUWINDI

PER/2210/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

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

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

13

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

14

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

3

7-1435751247

PUSKESMAS GABUS II

JL SADANG DS. KARANGREJO, KEC. GABUS

58183

4

7-1435773598

PUSKESMAS GEYER I

JL. RAYA SOLO PURWADADI, KEC. GEYER

58172

5

7-1435791349

PUSKESMAS GEYER II

DS. BANGSRI, KEC. GEYER

58172

6

7-1444349893

PUSKESMAS GODONG I

JL. RAYA SEMARANG, KEC. GODONG

58162

7

7-1444478904

PUSKESMAS GODONG II

DS. SAMBUNG, KEC. GODONG

58162

8

7-1444574355

PUSKESMAS GROBOGAN

JL. PUGER NO.160, KEC. GROBOGAN

58152

9

7-1444762696

PUSKESMAS GUBUG I

JL. A. YANI 119, KEC. GUBUG

10

7-1444853077

PUSKESMAS GUBUG II

11

7-1444951638

12

MA11222I

00551107

029265932 2


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58 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

15

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

16

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

17

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

18

7-1445782077

PUSKESMAS PENAWANGAN I

JL. RAYA PURWODADI, KEC. PENAWANGAN

58161

029242710 70

DR. DIANA FAJAR UDHARITA

PER/2218/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

19

7-1445869188

PUSKESMAS PENAWANGAN II

JL. RAYA SEDADI KM 3, KEC. PENAWANGAN

58161

DR. AGUS BUDI SARJONO, MM

PER/2219/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

20

7-1445943179

PUSKESMAS PULOKULON I

JL. RAYA . PANUNGGALAN NO 137, KEC. PULOKULON

58181

RIJADI AZIKIN, SKM, M.KES

PER/2220/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

21

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

22

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

23

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

24

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

25

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

26

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

081325129 862

029251351 50


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NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

029255219 2

TIPE IKS

AWAL IKS

AKHIR IKS

AGUS SETIJORINI, SKM

PER/2227/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

DR. ENDAH YULI RATNAWATI

PER/2228/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

DJAKA WIDADA B, SKM

445/1722/2014

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

SUTRISNO, SKM

PER/2230/112015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

DRG EDI SUMARWANTO MM MH KES

PER/25/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6725555

LIDIA MEGAWATI

PER/23/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL HAYAM WURUK NO 24 PURWODADI

422838

DR H UTOMO DS SPOG

PER/31/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

RS PERMATA MEDIKA

JL MOCH ICHSAN NO 93-97 NGALIYAN

7625005

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

1500000000211

RSUD DR R SOEDJATI SOEMODIARDJO

JL DI PANJAITAN 36 PURWODADI

421004

PER/30/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

37

1400000000216

RSUD KOTA SEMARANG

JL FATMAWATI NO 1 SEMARANG

6711500

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

1400000000214

RSUD TUGUREJO

JL. RAYA TUGUREJO KM 9 TAMBAK AJI NGALIYAN

7605297

PER/27/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

27

7-1446759157

PUSKESMAS TOROH I

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

58171

28

7-1446805408

PUSKESMAS TOROH II

DS. TUNGGAK, KEC.TOROH

58171

29

7-1446854619

PUSKESMAS WIROSARI I

JL. KUSUMA BANGSA, KEC. WIROSARI

58192

30

7-1446890010

PUSKESMAS WIROSARI II

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

58192

31

1400000000218

RS BHAKTI WIRA TAMTAMA

JL DR SOETOMO NO 17

3555944

32

1500000000212

RS ISLAM KENDAL

JL AR RAHMAH NO 17 WELERI KENDAL

641870

33

1400000000217

RS PELITA ANUGERAH

JL RAYA BANDUNGREJO KM 11.5 MRANGGEN

34

1500000000210

RS PERMATA BUNDA

35

1400000000219

36

MA11222I

029276102 9

DR BAMBANG PUJIYANTO M.KES


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NO

KODE PROVIDER

:

L01- KANTOR CABANG SURAKARTA

NAMA PROVIDER

ALAMAT

1

1500000000142

KLINIK GRIYA HUSADA 1

JL. MEKARSARI RT 03 RW 01 POPONGAN KARANGANYAR

2

1500000001791

KLINIK NAYAKA HUSADA 07 KARANGANYAR

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

3

1500000001215

KLINIK NGESTI HUSADA JATI

JL SUMPAH PEMUDA NO. G KADIPIRO

4

1400000000516

KLINIK NGUDI SEHAT

JL. TENTARA PELAJAR NO. 31 SANGGRAHAN GROGOL SUKOHARJO

5

1500000000106

KLINIK NGUDI SEHAT PARANGJORO

6

1500000000417

7

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR HADIASRI WIDIYASARI

PER/14/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016


PER/29/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

DR DEVI FIKASARI

PER/27/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

2974269

SUHADI

PER/18/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

SINGKIL RT 03 RW 08 PARANGJORO GROGOL SUKOHARJO

2974269

KLINIK NGUDI SEHAT PARANGJORO

PER/10/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

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

1400000000474

RS DR OEN SOLO BARU

PERUMAHAN SOLO BARU GROGOL

620220

RS DR OEN SOLO BARU

PER/07/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

8

1100000000033

RS DR OEN SURAKARTA

JL. BRIGJEND KATAMSO 55

643139

YYS PANTI KOSALA

PER/12/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

9

1500000001866

RS HERMINA SOLO

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

638989

PT MEDIKA LOKA SOLO

PER/30/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

10

1100000000034

RS KASIH IBU SURAKARTA

JL SLAMET RIYADI 404

714422

YYS KASIH IBU

PER/08/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

11

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

12

1100000000032

RS KUSTATI

JL KAPT MULYADI 249

643013

PER/09/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

MA11222I

6499639

57171

57116


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

13

1400000000536

RS NIRMALA SURI SUKOHARJO

JL SOLO SUKOHARJO KM 9

14

1100000000035

RS ORTHOPEDI PROF DR SOEHARSO

JL. JEND A YANI PABELAN

15

1100000000031

RS PANTI WALUYO

16

1500000000294

17

KODE POS

IKS TELEPON

PIMPINAN NO IKS

AWAL IKS

AKHIR IKS

PER/19/012016

RS.TRAUMA CENTRE

15/01/2016

31/12/2016

714458

PER/02/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

JL A YANI 1-2

712077

PER/15/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

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

1400000000537

RS PKU MUHAMADIYAH SURAKARTA

JL RONGGOWARSITO NO 130 SURAKARTA

714578


PER/20/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

18

1500000001946

RS PKU MUHAMMADIYAH KARANGANYAR

JL PAPAHAN DESA PAPAHAN KECAMATAN TASIKMADU

492685

YAYASAN MUHAMADIYAH

PER/31/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

19

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

20

08237

RS PKU MUHAMMADIYAH SURAKARTA

JL RONGGOWARSITO SURAKARTA


PER/20/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

21

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

22

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

23

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

24

1500000000687

RSU MARDI LESTARI

JL ROKAN NO 8 SRAGEN

YYS SANTA KATARINA L

PER/27/042015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

RS NIRMALA SURI SUKOHARJO

TIPE IKS

57171

714578

50771

71445832


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

31/12/2016

PER/03/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

PER/13/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

RSUD KABUPATEN KARANGANYAR

PER/04/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

593118

RSUD KABUPATEN SUKOHARJO

PER/05/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

715300

RSUD KOTA SURAKARTA

PER/06/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

JL ROKAN NO 8 SRAGEN

26

1100000000036

RSUD DR MOEWARDI SURAKARTA

JL KOL SUTARTO 132

27

1500000000120

RSUD DR SOEHADI PRIJONEGORO SRAGEN

JL RAYA SUKOWATI 534 SRAGEN

28

1400000000424

RSUD KABUPATEN KARANGANYAR

JL. LAKSDA YOS SUDARSO

495673

29

1400000000425

RSUD KABUPATEN SUKOHARJO

JL DR MOEWARDI 71 SUKOHARJO

30

1400000000423

RSUD KOTA SURAKARTA

JL. LETTU SUMARTO NOMOR : 1 KADIPIRO BANJARSARI

KODE PROVIDER

AKHIR IKS

11/01/2016

RSU MARDI LESTARI

NO

AWAL IKS

RS.TRAUMA CENTRE

1500000000687

:

TIPE IKS

PER/24/012016

25

KANTOR CABANG

PIMPINAN

YYS SANTA KATARINA L

634634

L02- KANTOR CABANG CILACAP

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

KANTOR CABANG

MA11222I

:

L03- KANTOR CABANG YOGYAKARTA


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

3

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

4

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

5

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

6

1400000000136

RS QUEEN LATIFA

JL RING ROAD BARAT MLANGI NOGOTIRTO GAMPING

581402

PER/48/122015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

7

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

8

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

9

1500000000327

RSUD KOTA YOGYAKARTA

JL WIROSABAN NO.1 YOGYAKARTA

371195

PEMKOT YOGYAKARTA

PER/01/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

10

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

11

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

12

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


SM0480



64 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

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

14

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

15

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

KANTOR CABANG

NO

:

KODE PROVIDER

L04- KANTOR CABANG PEKALONGAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000411

RS QOLBU INSAN MULIA (QIM)

JL URIP SUMOHARJO - SAMBONG

51211

4495222

PT QOLBU INSAN MULIA

PER / 24 /112015

RS.TRAUMA CENTRE

25/02/2016

31/10/2016

2

1400000000411

RS QOLBU INSAN MULIA (QIM)

JL URIP SUMOHARJO - SAMBONG

51211

4495222

PT QOLBU INSAN MULIA

PER / 24 /112015

RS.TRAUMA CENTRE

24/02/2016

31/10/2016

3

1500000000214

RSI PKU MUHAMMADIYAH

JL RAYA AMBOKEMBANG NO 42-43 KEDUNGWUNI

51173

785133

YAYASAN MUHAMMADIYAH

PER / 002 / 022016

RS.TRAUMA CENTRE

02/03/2016

31/12/2017

KANTOR CABANG

NO

1

KODE PROVIDER

7-1073301393

MA11222I

:

L05- KANTOR CABANG KUDUS

NAMA PROVIDER

KLINIK PRATAMA SEJAHTERA

ALAMAT

JL RA KARTINI NO 15 PATI

KODE POS

59111

IKS TELEPON

PIMPINAN NO IKS DR JOKO MARDIYANTO

PER.030/X/2015



AWAL IKS 07/01/2016


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65 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1500000000138

RSI SULTAN HADLIRIN JEPARA

JL RAYA JEPARA BANGSRI KM 3 DS KUWASEN

591507

RSI SULTAN HADLIRIN JEPARA

PER/003/012016

RS.TRAUMA CENTRE

02/02/2016

31/12/2017

3

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

4

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

5

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

6

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

7

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

8

1400000000558

RSUD RA KARTINI KABUPATEN JEPARA

JL. WACHID HASYIM NO.100

RSUD JEPARA

PER/004/022016

RS.TRAUMA CENTRE

22/02/2016

31/12/2016

9

7-1601479543

RSUD RAA SOEWONDO PATI

JL.DR. SUSANTO NO. 114 PATI

59163

DR. SUWORO NURCAHYONO.M.KES

PER/009/012016

RS.TRAUMA CENTRE

26/01/2016

31/12/2016

10

7-1061786478

RUMAH SAKIT KELUARGA SEHAT

JL P SUDIRMAN NO 9 MARGOREJO PATI

59163

295386111

SWASTA

8784/KSH/PKS/ XI/2015

RS.TRAUMA CENTRE

12/01/2016

01/09/2017

11

1500000000137

RUMAH SAKIT KUMALASIWI KUDUS

JL JEPARA KM 6 DESA MIJEN RT 10 RW 06 KALIWUNGU

4245551

RUMAH SAKIT KUMALASIWI KUDUS

PER/005/2016

RS.TRAUMA CENTRE

02/02/2016

31/12/2017

12

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

13

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

MA11222I

591175


SM0480



66 / 108 02-03-2016 13:40:34


NO

:

KODE PROVIDER

L06- KANTOR CABANG MAGELANG

NAMA PROVIDER

ALAMAT

AWAL IKS

AKHIR IKS

29/01/2016

31/12/2017

JL MAYJEN BAMBANG SUGENG KM 03 MENDOLO BUMIRESO

322961

YAYASAN AMAL DAN KESEJAHTERAAN UMAT ISLAM (YAKAUMI)

PER/01/012015

RS.TRAUMA CENTRE

29/01/2016

31/12/2015

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

2

1500000000113

RUMAH SAKIT ISLAM WONOSOBO

3

1500000000113

RUMAH SAKIT ISLAM WONOSOBO

54114

L07- KANTOR CABANG TEGAL

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

DR M KARIM AMRULLAH

PER/09/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

DR SUHARJO

PER/10/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

52415

DR SUWASPODO

PER/16/2016

RS.TRAUMA CENTRE

22/02/2016

31/01/2017

JL PASAR BALAMOA RT 01/01 PANGKAH

52415

DAWAM RAHARJO

PER/17/012016

RS.TRAUMA CENTRE

22/02/2016

31/12/2016

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

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

1

1500000001580

KLINIK AZ-ZAHRA

JL RAYA LEBAKSIU RT 02/03 LEBAKSIU LOR

2

1500000001579

KLINIK KS TUBUN 81

JL KS TUBUN NO 81 RT 01/01 KEL DEBONGTENGAH

3

7-2131721414

KLINIK MONAS WOUND CARE TEGAL

JL RAYA TALANG RT 11/02 TALANG

4

7-2131470963

KLINIK NAYAKA HUSADA 06 BALAMOA

5

1500000001755

6

1500000001756

MA11222I


JL. JENDERAL SUDIRMAN NO. 60 PURWOREJO

KODE PROVIDER

NO IKS PER/01/012016

RSUD DR TJITROWARDOJO PURWOREJO

NO

PIMPINAN RSUD DR TJITROWARDOJO PURWOREJO

7-1712506763

:

IKS TELEPON

275321118

1

KANTOR CABANG

KODE POS

081828983 6


SM0480



67 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

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

8

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

9

1500000000186

RS MITRA SIAGA

JL PALA RAYA NO 54 KEC KRAMAT

322550

PER/01/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1500000001754

RSU ADELLA

JL PROF MOH YAMIN NO 77 KEL KUDAILE KEC SLAWI

PER/11/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

01626

RSU KARDINAH TEGAL

JL KS TUBUN NO. 1 TEGAL

PER/14/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

0900000000035

RSUD DR SOESELO SLAWI (TC)

JL DR SUTOMO NO 63 SLAWI

491991

DR WIDODO JOKO MULYONO, M,KES,MMR

PER/04/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000001236

RSUD SURADADI

JL RAYA TEGAL-PEMALANG KM.12 SURADADI

3336263

PEMERINTAH KABUPATEN TEGAL

PER/08/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

0900000000029

RSUI HARAPAN ANDA (TC)

JL ABABIL NO 42

353387

HABIYAH. MMR

PER/03/2015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

1

KODE PROVIDER

1400000000435

MA11222I

:

52419

491154

DR H M ABDUL DJALIL MKES

L08- KANTOR CABANG KLATEN

NAMA PROVIDER

KLINIK INSAN SEHAT

ALAMAT

JL. RAYA BOYOLALI SELO KM 5 JELOK CEPOGO

KODE POS

IKS TELEPON

PIMPINAN NO IKS

081393306 461

PT RESTU BUNDA

PER/24/112015



AWAL IKS 04/01/2016


SM0480



68 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

2

7-1549815415

KLINIK NAYAKA HUSADA 02 BOYOLALI

DK. BUTUH MOJOSONGO BOYOLALI

3

1500000000102

KLINIK PKU MUH JATINOM

JL RAYA JATINOM KLATEN KM 1 KLATEN

337334

4

1500000000083

KLINIK PRATAMA RAWAT INAP MILA HUSADA

JL . RAYA PENGGING KM 02 BANYUDONO BOYOLALI

327453

5

0800000000001

RSI KLATEN

JL YOGYA-SOLO KETANDAN KLATEN

6

7-1550676406

RSU CAKRA HUSADA KLATEN

JL. MERBABU NO 7

7

0800000000004

RSU PANDAN ARANG BOYOLALI

8

0800000000002

9

0800000000005

KANTOR CABANG

NO

1

KODE PROVIDER

1400000000187

MA11222I

:

PIMPINAN YAYASAN DANA PENSIUN KARYAWAN BPJS KETENAGAKERJAAN YAYASAN MUHAMMADIYAH CAB JATINOM KLATEN

AWAL IKS

AKHIR IKS

PER/07/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

PER/06/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

PER/05/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PER/08/012016

RS.TRAUMA CENTRE

25/01/2016

31/12/2016

JL KANTIL 14 BOYOLALI

PER/02/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

RSU SOERADJI TIRTONEGORO

JL SURADJI TIRTONEGORO

PER/04/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

RSUD BANYUDONO

JL RAYA SOLO-SEMARANG

PER/03/012016

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

57322

024760562 1

TIPE IKS

57412

DR. H DIDIK SUPRAPTO

PT CAKRA HUSADA

085647136 655

PEMDA

L09- KANTOR CABANG PURWOKERTO

NAMA PROVIDER

RSI PURWOKERTO

ALAMAT

JL H MASYHURI NO 39 PURWOKERTO

KODE POS

IKS TELEPON

PIMPINAN NO IKS

630019

YARSI PURWOKERTO

PER/001/012016



AWAL IKS 21/01/2016


SM0480



69 / 108 02-03-2016 13:40:34


NO

KODE PROVIDER

:

L10- KANTOR CABANG UNGARAN

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000867

GRIYA PELATIHAN APAC (GRIPAC)

JL SOEKARNO HATTA KM.32 DESA HARJOSARI BAWEN

522914

PT APAC INTI CORPORA

PER/09/012016

RS.TRAUMA CENTRE

25/02/2016

31/12/2016

2

1400000000657

KLINIK APAC INTI CORPORA

JL SOEKARNO HATTA KM 32 HARJOSARI BAWEN

522888

H AGUNG WAHONO SH.MHUM

PER/06/012016

RS.TRAUMA CENTRE

13/01/2016

31/12/2016

3

1500000001574

KLINIK PRATAMA "MANUNGGAL"

JL ARGO BUSONO NO.1

322480

KOPERASI PT DAMATEX

PER/08/012016

RS.TRAUMA CENTRE

25/02/2016

31/12/2016

4

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

5

7-2008582105

PUSKESMAS AMBARAWA

JL JENDRAL SUDIRMAN NO 76 KEC AMBARAWA KAB SEMARANG

50611

DINAS KESEHATAN KABUPATEN SEMARANG

PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

6

7-2008950288

PUSKESMAS BANCAK

JL JENDRAL SUDIRMAN NO 1 KEC BANCAK KAB SEMARANG

50125

DINAS KESEHATAN KAB SEMARANG

PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

7

7-2008215164

PUSKESMAS BANYUBIRU

JL WIJAYA KUSUMA 47 KEC BANYUBIRU KAB SEMARANG

50664


PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

8

1500000000341

PUSKESMAS BAWEN

JL PALAGAN NO. 60 KEC. BAWEN

591539

DINAS KESEHATAN KAB.SEMARANG

PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

9

1500000000340

PUSKESMAS BERGAS

JL SOEKARNO HATTA KEC.BERGAS

6525695


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

10

7-2008826037

PUSKESMAS BRINGIN

JL DIPONOGORO NO 141 BRINGIN KEC BRINGIN KAB SEMARANG

50218


PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

11

7-1990357685

PUSKESMAS DADAPAYAM

JL RAYA DADAPAYAM NO.79, KEC SURUH

50186

029871088 02


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

12

1500000000338

PUSKESMAS DUREN

JL KENDALISODO NO.19 KEC.BANDUNGAN

711355


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

MA11222I


SM0480



70 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

13

7-2006436553

PUSKESMAS GEDANGAN

JL RAYA SALATIGA MUNCUL KM 3 KEC TUNTANG KAB SEMARANG

14

1500000000325

PUSKESMAS GETASAN

15

1500000000337

16

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

024692123 8

DINKES KAB SEMARANG

PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

JL RAYA SALATIGA KOPENG KM 10 KEC.GETASAN

2838099


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

PUSKESMAS JAMBU

JL. RAYA SEMARANG MAGELANG KM 4 KEC.JAMBU

593532


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

7-1989943593

PUSKESMAS JETAK

DS.JETAK , KEC.GETASAN

50774

029831466 4

DINKES KAB SEMARANG

PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

17

7-2008732846

PUSKESMAS JIMBARAN

JL TEGAL PANAS JIMBARAN KEC BAWEN KAB SEMARANG

50661


PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

18

7-1990221924

PUSKESMAS KALIWUNGU

JL AMPEL SIMO 186, KEC.KALIWUNGU

50221

DINKES KAB SEMARANG

PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

19

7-2009520872

PUSKESMAS KALONGAN

JL ARJUNA NO 2 KE UNGARAN TIMUR KAB SEMARANG

50514


PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

20

7-2009063660

PUSKESMAS LEREP

JL YUDISTIRA RAYA KM 3 KEC UNGARAN TIMUR KAB SEMARANG

50514


PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

21

7-2009405851

PUSKESMAS LEYANGAN

JL PUSKESMAS NO 1 KEC UNGARAN BARAT KAB SEMARANG

50512


PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

22

7-1990444836

PUSKESMAS PABELAN

JL PEMUDA NO.98 PABELAN, KEC,PABELAN

50771

029832112 4


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

23

1500000000339

PUSKESMAS PRINGAPUS

JL.HONGOWICONO NO.5 KEC. PRINGAPUS

25721150

DNIAS KESEHATAN KAB.SEMARANG

PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

24

7-1990583417

PUSKESMAS SEMOWO

DS SEMOWO , KEC. PABELAN

029871009 85


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

MA11222I

50131

50771

027633312 13


SM0480



71 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

25

1500000000336

PUSKESMAS SUMOWONO

JL.PAHLAWAN NO.15 KEC SUMOWONO

40575050


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

26

1500000000343

PUSKESMAS SURUH

JL RAYA SURUH PLUMBON KEC SURUH

2882262


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

27

1500000000342

PUSKESMAS SUSUKAN

JL RAYA SUSUKAN NO.96 KEC SUSUKAN

615066


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

28

1500000000344

PUSKESMAS TENGARAN

JL RAYA SALATIGA SOLO KM 9 KEC. TENGARAN


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

29

7-1990928198

PUSKESMAS TUNTANG

JL FATMAWATI NO.47, KEC TUNTANG

50131


PER/07/012016

RS.TRAUMA CENTRE

12/02/2016

31/12/2016

30

7-2009013889

PUSKESMAS UNGARAN

JL AHMAD YANI NO 2-3 KEC UNGARAN KAB SEMARANG

50511


PER/07/012016

RS.TRAUMA CENTRE

15/02/2016

31/12/2016

31

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

32

1400000000019

RSUD AMBARAWA

JL KARTINI NO. 101 AMBARAWA

591020

PEMDA KAB SEMARANG

PER/02/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

33

7-1395288578

RSUD KOTA SALATIGA

JL OSAMALIKI NO. 19 SALATIGA

PEMKOT SALATIGA

PER/03/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

34

01728

RSUD SALATIGA

JL OSAMALIKI NO 19 SALATIGA

324074

KOTA MAGELANG

PER/03/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

35

1400000000018

RSUD UNGARAN

JL DIPONEGORO NO. 125 UNGARAN

6921006

PEMDA KAB.SEMARANG

PER/01/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

KANTOR CABANG

MA11222I

:

029834000 7

50721

L11- KANTOR CABANG SEMARANG KALIGAWE


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

1500000001891

KLINIK 24 JAM DELIMA SEHAT

JL FATMAWATI NO 21A SEMARANG

2

1500000001494

KLINIK KAWAN SEJATI

3

1500000001534

4

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

6734367

DR. DODI WITJAKSONO

PER/15/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

DS KARANGSARI RT 01/04 KARANGTENGAH DEMAK

089671458 335

NINDYA ANGGI SINANTARA

PER/09/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

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

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

5

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

6

1400000000261

KLINIK PRATAMA NAYAKA ERA HUSADA 03

JL RAYA KALIGAWE KM5,5

70572297

PT NAYAKA ERA HUSADA SEMARANG

PER/04/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

7

1500000001381

KLINIK PRATAMA NAYAKA HUSADA 04

JL SEMARANG-DEMAK KM 15 WONOKERTO KARANGTENGAH DEMAK

7605621


PER/08/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

8

1500000001380


JL SULTAN FATAH NO 47 DEMAK

7605621


PER/07/012016

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

9

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

10

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

11

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

12

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

MA11222I

50111


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

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

14

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

15

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

:

N00- KANTOR CABANG SURABAYA KARIMUNJAWA

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000715

ANUGERAH KARYA MEDIKA CEMENGKALANG SIDOARJO

RUKO PURI INDAH BLOK 30,JATICEMENGKALANG-SIDOARJO

031715542 59

SUSILO HENDROWARSITO

PER/09/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

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

3

1500000000720

ANUGERAH KARYA MEDIKA GUNUNGSARI

JL. GUNUNGSARI NO.124 SURABAYA

5675589

CV. ANUGERAH KARYA MEDIKA

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

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

5

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

6

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

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

7

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

8

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

9

1500000001071

KLINIK KENCANA MEDIKA

JL. KENDANGSARI NO. 78 SURABAYA

8498880

KLINIK KENCANA MEDIKA

PER/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

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

11

1500000001072

KLINIK MEDPOINT

JL. RAYA LONTAR 229 SURABAYA

7524067

KLINIK MEDPOINT

PER/16/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

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

13

1400000000445


JL RAYA KRIKILAN NO 259 DRIYOREJO GRESIK

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

1400000000450


JL RA KARTINI NO 236 C-9 KEBOMAS GRESIK

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

1400000000449


RUKO SEPANJANG TOWN HOUSE C1-C3 JL KALIJATEN

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

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

17

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

18

1500000000718

KLINIK PRATAMA ALAMANDA

JL. DINOYO NO.20-II

5677767

CV. INTI PRATAMA

PER/19/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

19

1400000000443

KLINIK PRATAMA NAYAKA 02

JL MASTRIP NO 150 KEBRAON SURABAYA

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1400000000439


JL CENDRAWASIH NO 28B

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1400000000446


JL ASEM ROWO KALI NO 1

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

1400000000447


JL PANDEGILING NO 117A

7887273


PER/17/012015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1400000000448


JL TANDES ASRI NO 64

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1400000000451


JL KALI RUNGKUT NO 52

7887273


PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

25

1500000001483

KLINIK PRATAMA PG KREMBOONG

DESA KREMBOONG SIDOARJO

081332074 648

PTPN X

PER/24/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

26

1500000001483

KLINIK PRATAMA PG KREMBOONG

DESA KREMBOONG SIDOARJO

081332074 648

PTPN X

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

27

1500000001484

KLINIK PRATAMA PG TOELANGAN

DESA TULANGAN SIDOARJO

PTPN X

PER/24/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

1500000001484

KLINIK PRATAMA PG TOELANGAN

DESA TULANGAN SIDOARJO

PTPN X

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

29

1500000001485

KLINIK PRATAMA PG WATOETOELIS

DESA TEMU KECAMATAN PRAMBON SIDOARJO

081332074 648

PTPN X

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

30

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

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

31

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

32

1500000001029

KLINIK UTAMA KASIH KARUNIA

JL. RAYA SATELIT BARAT AS NO.1 SURABAYA

7327688

YAYASAN KASIH KARUNIA

PER/21/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

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

34

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

35

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

36

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

37

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

38

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

39

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

40

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

41

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

KANTOR CABANG

MA11222I

:

N01- KANTOR CABANG KEDIRI


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1000000000008

RS BHAYANGKARA KEDIRI

JL.KOMBES POL. DURYAT NO. 17 KEDIRI

POLRI

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1000000000008

RS BHAYANGKARA KEDIRI

JL.KOMBES POL. DURYAT NO. 17 KEDIRI

POLRI

PER/33/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

07189

RS BHAYANGKARA NGANJUK

JL. ABDUL RAHMAN SALEH NO. 52-56

3218896

PER/23/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1500000000725

RSU AURA SYIFA

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

5

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

6

1500000001542

RSUD KABUPATEN KEDIRI

JLN. PAHLAWAN KUSUMA BANGSA NO. 1 PARE KEDIRI

391718

RSUD KABUPATEN KEDIRI

PER/29/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7

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

8

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

9

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

10

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

11

1500000000723

RUMAH SAKIT MUHAMMADIYAH SITI KHODIJAH

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

545481

RUMAH SAKIT MUHAMMADIYAH SITI KHODIJAH

PER/32/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

MA11222I

:

N02- KANTOR CABANG MALANG


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

AWAL IKS

AKHIR IKS

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

ABNASAMANHUDI SAUTIKA HUSADA PT

PER/11/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

879047

YAYASAN RS GONDANGLEGI

PER/04/01/01201 6

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL. RAYA SUKOSARI 32 KASEMBON

326688

YAY AL MADINAH

PER/12/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

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

8

1000000000011

RUMAH SAKIT MARSUDI WALUYO

JL.RAYA MONDOROKO KM 9 SINGOSARI MALANG

458919

DR.KRISTIWI HANGGRIYANI

PER/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1000000000011

RUMAH SAKIT MARSUDI WALUYO

JL.RAYA MONDOROKO KM 9 SINGOSARI MALANG

458919

DR.KRISTIWI HANGGRIYANI

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

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

11

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

12

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

1

1300000000016

RS. BAPTIS BATU

JL. RAYA TLEKUNG NO.1 JUNREJO

594161

2

1200000000012

RS. BHAYANGKARA HASTA BRATA

JL. RA KARTINI NO. 01

597023

3

1200000000008

RS. WAVA HUSADA

JL. PANGLIMA SUDIRMAN NO. 99 A DILEM KEPANJEN

393000

4

1500000000046

RSI GONDANGLEGI

JL HAYAM WURUK NO 66 GONDANGLEGI

5

1400000000002

RSU ISLAM MADINAH

6

1200000000009

7

MA11222I

YAYASAN BAPTIS INDONESIA

TIPE IKS


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

13

1400000000001

RUMAH SAKIT UMUM DAERAH DR. SAIFUL ANWAR

JL. JAKSA AGUNG SUPRAPTO

362101

PEMPROV JATIM

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

14

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

15

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

16

1500000001316

UPT PELATHAN KERJA SINGOSARI

JL. RAYA SINGOSARI

458055

UPT PELATHAN KERJA SINGOSARI

PER/15/012016

RS.TRAUMA CENTRE

04/02/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

N03- KANTOR CABANG JEMBER

NAMA PROVIDER

ALAMAT

1

1400000000625

RS BHAYANGKARA BONDOWOSO

JL JEND POL SUCIPTO JUDODIHARJO NO 12 BONDOWOSO

2

7-1672273183

RS CITRA HUSADA

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

3

7-1672273183

RS CITRA HUSADA

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

4

1400000000626

RS ISLAM LUMAJANG

JL KYAI MUKSIN 19 LUMAJANG

5

7-1692033973

RS JEMBER KLINIK

JALAN BEDADUNG NO.2 JEMBER LOR PATRANG JEMBER

MA11222I

65311

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

082336624 828

DR EKA WARDHANI

PER/22/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

68117

033148620 0

YAYASAN CITRA HUSADA

PER/004/012016

RS.TRAUMA CENTRE

01/02/2016

31/01/2017

68117

033148620 0

YAYASAN CITRA HUSADA

PER/4/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

887999

DR R ELYUNAR DWI NUGROHO

PER/20/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

033148710 4

PT NUSANTARA MEDIKA UTAMA

PER/05/012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

68111


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

6

1400000000009

RSU KALIWATES JEMBER

JL DIAH PITALOKA NO 4 A JEMBER

7

7-1938064553

RSUD DR HARYOTO KAB LUMAJANG

JL BASUKI RAHMAD NO 5 LUMAJANG

KANTOR CABANG

NO

KODE PROVIDER

:

KODE POS

67311

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

485967

PT ROLAS NUSANTARA MEDIKA

PER/21/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

033488166 6

PEMPROV

PER/007/022016

RS.TRAUMA CENTRE

22/02/2016

31/12/2016

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/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

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

3

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

4

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

5

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

6

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

7

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

MA11222I


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

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

9

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

10

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

11

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

12

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

13

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

14

1400000000264

RSI MASYITHOH

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

741018

YAYASAN

IKS/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

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

KANTOR CABANG

NO

1

KODE PROVIDER

1500000001601

MA11222I

:

N05- KANTOR CABANG MOJOKERTO

NAMA PROVIDER

BP JAMSOSTEK 106

ALAMAT

JL RAYA WONOSARI NO 112 NGORO

KODE POS

61385

IKS TELEPON

PIMPINAN NO IKS

6817998

IR H TEUKU ISMAIL

PER/48/122015



AWAL IKS 01/01/2016


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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

1500000001598

KLINIK PRATAMA MITRA 12

JL ANGGREK NO 24 CANDIMULYO

61411

DR MERIDIAN GEODESI

PER/47/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1500000001605


JL PANGLIMA SUDIRMAN NO 26 KEC PLOSO

61453

DR WIWIET SARASWATI

PER/52/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001599


JL RAYA TROWULAN NO132 KEC TROWULAN

61362

492876

CV MITRA HUSADA

PER/49/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000001600


JL RAYA JETIS NO 14

61352

363786

IR H TEUKU ISMAIL

PER/50/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000001595

KLINIK PRATAMA SURYA HUSADA 2

JL RAYA PRAMBON DS NGIMBANG MOJOSARI

61384

SITI NUR HIDAYATI ST MKES

PER/44/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

878318


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

14

1500000001596

KLINIK SURYA HUSADA

RAYA TRAWAS DSN WRINGINANOM DS MOJOREJO

61384

15

1500000001608

RS AL AZIZ

JL RAYA TEMBELANG KEC TEMBELANG

61453

16

0900000000027

RS EMMA (RS TC)

JL RAYA IJEN NO 67

17

1500000000353

RS GATOEL

JL RADEN WIJAYA NO 56 KRANGGAN, PRAJURIT KULON

18

1500000000927

RS KAMAR MEDIKA

JL EMPUNALA NO 351 KEDUNDUNG MAGERSARI

19

1500000000925

RS MUTIARA HATI

JL RAYA KEMANTREN WETAN NO 49 TERUSAN GEDEG

20

1500000001594

RS NAHDLATUL ULAMA JOMBANG

JL KH HASYIM ASYARI NO 211

21

1500000001522

RS PELENGKAP MEDICAL CENTER

JL IR JUANDA NO 03

22

0800000000011

RS SIDO WARAS (RS TC)

23

0800000000034

24

25

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

SITI NUR HIDAYATI ST MKES

PER/43/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

853757

YAYASAN AL AZIZ

PER/67/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

61311

032132873 7

DR MAGDALENA SITORUS

PER/64/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

61319

328557

PT NUSANTARA MEDIKA UTAMA

PER/63/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

330066

PT WAK KAMAR MEDIKA HOSPITAL

PER/65/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

363442

SULFAKAR DR SPOG

PER/66/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

878700

PT RUMAH SAKIT NAHDLATUL ULAMA JOMBANG

PER/69/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

61411

877945

PT PELANGKAP MEDICA SEJAHTERA

PER/68/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

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

1500000001523

RSI HASANAH

JL HOS COKROAMINOTO NO 26-28 MOJOKERTO

PER/70/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

1500000001621

RSI JOMBANG

JL BRIGJEN KRETARTO NO 22 A

PER/58/122015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

MA11222I

61351

321635

61411

860074

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


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

26

0800000000033

RSI SAKINAH (RS TC)

JL R A BASUNI NO 12

61361

321922

27

0800000000010

RSUD. PROF. DR. SOEKANDAR (RS TC)

JL HAYAM WURUK NO 25 MOJOSARI

61382

591591

28

1500000000347

RUMAH SAKIT KRISTEN MOJOWARNO

JL MERDEKA NO 59 MOJOWARNO

61475

495093

KANTOR CABANG

NO

KODE PROVIDER

:

PIMPINAN

DR SULAIMAN ROSYID

YAYASAN KESEHATAN GKJW

TIPE IKS

AWAL IKS

AKHIR IKS

PER/61/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PER/59/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PER/57/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

N06- KANTOR CABANG BANYUWANGI

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000827

KLINIK BRAWIJAYA

JL BRAWIJAYA NO 46 KEBALENAN

423711

DR EDI HERMANTO

PER/07/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

2

1500000000832

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

3

7-1989906563

RS NAHDLATUL ULAMA BANYUWANGI

JL RAYA MANGIR NO 09 KEC ROGOJAMPI

632965000

PC NAHDLATUL ULAMA KABUPATEN BANYUWANGI

PER/11/012016

RS.TRAUMA CENTRE

11/02/2016

31/12/2016

4

1200000000005

RS YASMIN

JL LETKOL ISTIQLAH 80-84

421198

YAYASAN SUMBER WARAS

PER/01/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

1400000000010

RSU BHAKTI HUSADA KRIKILAN

KRIKILAN GLENMORE

821118

PT ROLAS NUSANTARA MEDIKA

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6

1500000001552

RSUD ASEMBAGUS SITUBONDO

JL RAYA ASEMBAGUS KECAMATAN ASEMBAGUS

452193

PER/06/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I

68462


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

31/12/2016

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

845839

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

672054

PER/09/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL OLAHRAGA NO 55 BESUKI

891118

8

1400000000672

RSUD BLAMBANGAN BANYUWANGI

JL LETKOL ISTIQLAH BANYUWANGI

421118

9

1500000000826

RSUD GENTENG BANYUWANGI

JL HASANUDDIN NO 98 GENTENG

10

1500000001576

UPT PELATIHAN KERJA SITUBONDO

JL BASUKI RAHMAT NO 357

KODE PROVIDER

AKHIR IKS

01/01/2016

RSUD BESUKI

NO

AWAL IKS

RS.TRAUMA CENTRE

1500000001392

:

TIPE IKS

PER/05/012016

7

KANTOR CABANG

PIMPINAN

PEMDA BANYUWANGI

N08- KANTOR CABANG BLITAR

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

KANTOR CABANG

NO

1

KODE PROVIDER

1400000000233

MA11222I

:

N09- KANTOR CABANG MADURA

NAMA PROVIDER

PUSKESMAS TLANAKAN

ALAMAT

JL RAYA TLANAKAN PAMEKASAN

KODE POS

IKS TELEPON

PIMPINAN NO IKS

325568

PUSKESMAS

PER/01/012016



AWAL IKS 01/01/2016


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

31/12/2016

662494

PER/03/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL RAJAWALI NO 10

323956

PER/02/022016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL PEMUDA KAFFA NO. 9 BANGKALAN

3095088

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL KH MOCH KHOLIL 36A BANGKALAN

3095148

3

1400000000436

RSUD DR H MOH ANWAR SUMENEP

JL DR CIPTO NO 42 SUMENEP

4

1500000000235

RSUD SAMPANG

5

1400000000520

RSUD SYARIFAH AMBAMI RATO EBO BANGKALAN

KODE PROVIDER

AKHIR IKS

01/01/2016

RS LUKAS BANGKALAN

NO

AWAL IKS

RS.TRAUMA CENTRE

1400000000437

:

TIPE IKS

PER/04/012016

2

KANTOR CABANG

PIMPINAN

PHILIP

N10- KANTOR CABANG BOJONEGORO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

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

2

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

KANTOR CABANG

NO

1

KODE PROVIDER

1500000001401

MA11222I

:

N11- KANTOR CABANG SIDOARJO

NAMA PROVIDER

PUSKESMAS BALONGBENDO

ALAMAT

JL MAYJEN BAMBANG SUWONO NO 11 SEDURI

KODE POS

IKS TELEPON




AWAL IKS 01/01/2016


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

2

1500000001372

PUSKESMAS BARENGKRAJAN

DS BARENGKRAJAN KEC KRIAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3

1500000001363

PUSKESMAS BUDURAN

JL JAWA NO 2 KEC BUDURAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1500000001354

PUSKESMAS CANDI

JL M RIDWAN NO 5 GELAM KEC CANDI

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

1500000001368

PUSKESMAS GANTING

JL SINGO MENGGOLO NO 1 DS GANTING

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

6

1500000001367

PUSKESMAS GEDANGAN

JL RAYA GEDANGAN 330 KEC GEDANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

7

1500000001352

PUSKESMAS JABON

JL DUKUH SARI KEC JABON

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8

1500000001346

PUSKESMAS KEDUNG SOLO

DS KEDUNG SOLO KEC PORONG

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

9

1500000001356

PUSKESMAS KEPADANGAN

DS KEPADANGAN KEC TULANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

10

1500000001344

PUSKESMAS KREMBUNG

JL SUNGAI KAPUAS NO 2 KEC KREMBUNG

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

11

1500000001371

PUSKESMAS KRIAN

JL SETIA BUDI KEC KRIAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

12

1500000001366

PUSKESMAS MEDAENG

JL JOYOBOYO 40 MEDAENG KEC WARU

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

1500000001345

PUSKESMAS PORONG

JL JUWET UTARA 265 KEC PORONG

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


SM0480



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Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

14

1500000001343

PUSKESMAS PRAMBON

JL RAYA PRAMBAON KEC PRAMBON

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

15

1500000001364

PUSKESMAS SEDATI

DS BETRO KEC SEDATI

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

1500000001361

PUSKESMAS SEKARDANGAN

JL WIJAYA KUSUMA NO 91 SEKARDANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

17

1500000001359

PUSKESMAS SIDOARJO

JL DR SOETOMO NO 14 KEC SIDOARJO

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

18

1500000001358

PUSKESMAS SUKODONO

DS PEKARUNGAN KEC SUKODONO

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

19

1500000001369

PUSKESMAS TAMAN

JL RAYA NGELOM 50 KEC TAMAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

20

1500000001353

PUSKESMAS TANGGULANGIN

JL RAYA PUTAT NO 38 KEC TANGGULANGIN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

1500000001342

PUSKESMAS TARIK

JL RAYA KEMUNING KEC TARIK

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

22

1500000001370

PUSKESMAS TROSOBO

JL RAYA TROSOBO KEC TAMAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

1500000001355

PUSKESMAS TULANGAN

JL RAYA KEMANTREN KEC TULANGAN

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

24

1500000001360

PUSKESMAS URANGAGUNG

JL RAYA CEMENG KALANG KEC SIDOARJO

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

25

1500000001365

PUSKESMAS WARU

JL BARITO POJOK NO 1 WISTROP KEC WARU

PER/26/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

MA11222I


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89 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

31/12/2016

PER/25/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

PER/21/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

YYS MUHAMMADIYAH

PER/23/12205

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

8974943

YAYASAN RUMAH SAKIT ANWAR MEDIKA

PER/22/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL KH SAMANHUDI NO 85

8962129

YAYASAN USADA KARYA

PER/24/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL MAJAPAHIT NO 667

8961649

PER/20/122015

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

JL WONOAYU KEC WONOAYU

27

1400000000128

RS BUNDA SIDOARJO

JL KUNDI NO 70 KEPUH KIRIMAN WARU

8668880

28

0800000000036

RS CITRA MEDIKA

JL.RAYA SURABAYA-MOJOKERTO KM 44

361000

29

1300000000030

RS SITI KHODIJAH

JL PAHLAWAN NO 260 SEPANJANG

7882123

30

1400000000278

RSU ANWAR MEDIKA

JL RAYA BY PASS KRIAN KM 33 BALONGBENDO

31

1200000000014

RSU JASEM

32

0700000000008

RSUD SIDOARJO

KODE PROVIDER

PT PERMATA BUNDA BERSAMA

N12- KANTOR CABANG GRESIK

NAMA PROVIDER

ALAMAT

1

1500000000811

BP PANGLIMA SUDIRMAN GRESIK

JL PANGLIMA SUDIRMAN

2

1500000001618

FKTP POLRES GRESIK

JL BASUKI RAHMAT 2 GRESIK

MA11222I

AKHIR IKS

01/01/2016

PUSKESMAS WONOAYU

NO

AWAL IKS

RS.TRAUMA CENTRE

1500000001357

:

TIPE IKS

PER/26/122015

26

KANTOR CABANG

PIMPINAN

KODE POS

IKS TELEPON

PIMPINAN NO IKS

085631864 35

TIPE IKS

AWAL IKS

AKHIR IKS

YUNI HIDAYATI

PER/12/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

DR. BUDIYONO, MARS

PER/14/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016


SM0480



90 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

3

1500000000810

KLINIK HIDAYAH MANYAR

MANYAR RESORT

085631864 35

YUNI HIDAYATI

PER/11/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

1400000000627

KLINIK KELUARGA BAHAGIA

JL. RAYA WRINGINANOM KM.33.6

81180888

NOVEL MUHAMMAD RAMZY

PER/17/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

1500000000741

PUSKESMAS DRIYOREJO GRESIK

RAYA DRIYOREJO GRESIK

23264794

DR DANIEL SA'U

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

13

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

14

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


SM0480



91 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

15

1500000000742

PUSKESMAS GENDING GRESIK

JL VETERAN GRESIK

3985872

DRG HELENA SUZANA

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

16

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

17

1500000000890

PUSKESMAS KARANGANDONG GRESIK

RAYA KARANGANDONG DRIYOREJO GRESIK

7911659

DR SITI HAFIDA

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

18

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

19

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

20

1500000001565

PUSKESMAS KEPATIHAN GRESIK

RAYA KEPATIHAN 151

7991403

DRG TITIEK SRI HAJATI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

21

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

22

1500000001617

PUSKESMAS MANYAR GRESIK

JL RAYA MANYAR 1 GRESIK

DRG JON SUDIRO

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

23

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

24

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

25

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

26

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


SM0480



92 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

27

1500000001488

PUSKESMAS PANCENG GRESIK

JL RAYA PANCENG GRESIK

3940118

DR. JAIMAN

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

28

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

29

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

30

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

31

1500000001567

PUSKESMAS SLEMPIT GRESIK

RAYA SLEMPIT KEDAMEAN GRESIK

7911963

DR. SUKADI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

32

1500000000175

PUSKESMAS SUKOMULYO

JL. KALIMANTAN NO.104 GKB GRESIK

3954818

DR LESTARI

PER/05/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

33

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

34

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

35

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

36

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

37

1500000001983

RS FATHMA MEDIKA

JL. PENDOPO 45 SEMBAYAT MANYAR

3943500

DR. ASLUCHUL ALIF

PER/15/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

38

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

MA11222I

61111


SM0480



93 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

TIPE IKS

AWAL IKS

AKHIR IKS

01/01/2016

31/12/2016

DR TITIN

PER/13/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

3981275

DR.MUSA GHUFRON

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

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

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

SURYA GIRI JAYA CERME

JL. RAYA CERME GRESIK

63186435

YUNI HIDAYATI

PER/10/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

LABAN KULON 58 MENGANTI

40

1500000001519

RS WATES HUSADA

RAYA BALONG PANGGANG GRESIK

41

1400000000364

RS.MUHAMMADIYAH GRESIK

JL.KH.KHOLIL NO.88

42

1400000000363

RSI DARUS SYIFA' BENOWO

43

0900000000002

44

1500000000809

KODE PROVIDER

NO IKS

RS.TRAUMA CENTRE

RS SURYA MEDIKA GRESIK

NO

PIMPINAN

PER/16/012016

1500000001993

:

IKS TELEPON

RS RAMLI TARIGAN

39

KANTOR CABANG

KODE POS

61174

7914025

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/06/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

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

20/01/2016

31/12/2016

MA11222I


SM0480



94 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

4

1500000001445

BP HIDAYAH WARU IV

JL GRAHA TIRTA RAYA I NO.28 WARU

70350252

CV KEMBANG TANJUNG

PER/07/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

5

1500000001445

BP HIDAYAH WARU IV


70350252

CV KEMBANG TANJUNG

PER/07/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

6

1500000001445

BP HIDAYAH WARU IV


70350252

CV KEMBANG TANJUNG

PER/07/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

7

1500000001444

BP KEBANGKITAN

JL MANUKAN MADYA 141 SURABAYA

71258886

CV KEMBANG TANJUNG

PER/08/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

8

1500000001444

BP KEBANGKITAN


71258886

CV KEMBANG TANJUNG

PER/08/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

9

1500000001444

BP KEBANGKITAN


71258886

CV KEMBANG TANJUNG

PER/08/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

10

1500000001443

BP KESAYANGAN

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

8700691

CV KEMBANG TANJUNG

PER/09/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

11

1500000001443

BP KESAYANGAN


8700691

CV KEMBANG TANJUNG

PER/09/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

12

1500000001443

BP KESAYANGAN


8700691

CV KEMBANG TANJUNG

PER/09/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

13

1500000001446

BP KESEJAHTERAAN

JL RUNGKUT MAPAN UTARA AA-17 SURABAYA

8706755

CV KEMBANG TANJUNG

PER/10/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

14

1500000001446

BP KESEJAHTERAAN


8706755

CV KEMBANG TANJUNG

PER/10/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

15

1500000001446

BP KESEJAHTERAAN


8706755

CV KEMBANG TANJUNG

PER/10/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

MA11222I


SM0480



95 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

16

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

17

1500000001393

KLINIK KARYA MEDIKA 104

JL BANYU URIP NO 302 SURABAYA

5324326

CV KARYA MEDIKA

PER/16/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

18

1500000001393



5324326

CV KARYA MEDIKA

PER/16/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

19

1500000001393



5324326

CV KARYA MEDIKA

PER/16/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

20

1500000001394


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

CV KARYA MEDIKA

PER/17/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

21

1500000001394



CV KARYA MEDIKA

PER/17/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

22

1500000001394



CV KARYA MEDIKA

PER/17/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

23

1500000001395


JL NGAGLIK NO 47 SURABAYA

3764782

CV KARYA MEDIKA

PER/18/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

24

1500000001395



3764782

CV KARYA MEDIKA

PER/18/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

25

1500000001395



3764782

CV KARYA MEDIKA

PER/18/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

26

1500000001379

KLINIK SARTIKA 36

BRATANG BINANGUN GANG VI/47 SURABAYA

34417343

DR LILIK SRI HARTINI

PER/11/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

27

1500000001379

KLINIK SARTIKA 36


34417343


PER/11/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

MA11222I


SM0480



96 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

28

1500000001379

KLINIK SARTIKA 36


34417343


PER/11/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

29

1500000001377

KLINIK SARTIKA 44

JL RAYA MASTRIP NO 32 KARANG PILANG SURABAYA

34200705


PER/12/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

30

1500000001377

KLINIK SARTIKA 44


34200705


PER/12/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

31

1500000001377

KLINIK SARTIKA 44


34200705


PER/12/012016

RS.TRAUMA CENTRE

01/02/2016

31/12/2016

32

1500000001376

KLINIK SARTIKA 59

JL MANUKAN TENGAH 9K/10 SURABAYA

34183507


PER/13/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

33

1500000001317

KLINIK SARTIKA 77

JL TRUNOJOYO NO 2 SEPANJANG

7871549


PER/14/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

34

1500000001373

POLIKLINIK PUTRI RAHAYU

JL MASTRIP IX/9 WARUGUNUNG KARANGPILANG

7667983

BILAL ZAENAL ABIDIN

PER/05/012016

RS.TRAUMA CENTRE

29/01/2016

31/12/2016

35

1500000001373



7667983

BILAL ZAENAL ABIDIN

PER/05/012016

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

36

1500000001373



7667983

BILAL ZAENAL ABIDIN

PER/05/012016

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

37

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

38

1100000000008

RS BUNDA SURABAYA

JL RAYA KANDANGAN 23-24

7440077

PT PERMATA BUNDA BERSAMA

PER/02/012015

RS.TRAUMA CENTRE

04/01/2016

31/12/2016

39

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

MA11222I


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97 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

40

KODE PROVIDER

1400000000385

KANTOR CABANG

NO

NAMA PROVIDER

RS WIYUNG SEJAHTERA

:

KODE PROVIDER

ALAMAT

KODE POS

JL KARANGAN PDAM NO 1-3 WIYUNG SURABAYA

IKS TELEPON

PIMPINAN NO IKS

7532653

PT WIYUNG SEJAHTERA

PER/04/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

07/01/2016


N14- KANTOR CABANG SURABAYA TANJUNG PERAK

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000517

KLINIK WISMA HUSADA

JL DUKUH SETRO 7A KAV NO 2

PER/ 01/ 01-2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

2

1400000000517

KLINIK WISMA HUSADA

JL DUKUH SETRO 7A KAV NO 2

PER/ 01/ 012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

3

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

4

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

5

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

KANTOR CABANG

NO

1

KODE PROVIDER

1100000000022

MA11222I

:

N15- KANTOR CABANG SURABAYA RUNGKUT

NAMA PROVIDER

RS ISLAM SURABAYA JEMURSARI

ALAMAT

JL JEMURSARI 51-57

KODE POS

60236

IKS TELEPON

PIMPINAN NO IKS

847187778

YAYASAN RS ISLAM SURABAYA

PER/01/082015



AWAL IKS 08/01/2016


SM0480



98 / 108 02-03-2016 13:40:34


NO

:

KODE PROVIDER

P00- KANTOR CABANG PONTIANAK

NAMA PROVIDER

ALAMAT

1

1400000000383

RSUD KABUPATEN SANGGAU

JL JENDRAL SUDIRMAN

2

1400000000464

RUMAH SAKIT UMUM BETHESDA SERUKAM

JL. RAYA BENGKAYANG KM 48 SERUKAM

KANTOR CABANG

NO

1

KODE PROVIDER

RUMAH SAKIT UMUM DAERAH KOTABARU

:

KODE PROVIDER

ALAMAT

ALAMAT

1300000000039

RSUD DR SOEMARNO SOSROADMODJO

JL TAMBUN BUNGAI NO 16 KAPUAS

2

7-2201647033

UPT PUSKESMAS TANGKILING PALANGKARAYA

JL TJILIK RIWUT KM 34 KEL TANGKILING KEC BUKIT BATU

MA11222I

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

21070

DR. H. EDY SUPRABOWO, MKM

PER/02/012016

RS.TRAUMA CENTRE

24/02/2016

31/12/2016

637019

DR. EDY ARISTON LUBIS, SPM., M.SC

PER/11/022016

RS.TRAUMA CENTRE

24/02/2016

31/01/2017

IKS TELEPON

PIMPINAN NO IKS

22945

PER/01/012016

TIPE IKS

AWAL IKS

RS.TRAUMA CENTRE

01/01/2016


R03- KANTOR CABANG PALANGKARAYA

NAMA PROVIDER

:

KODE POS

JL.H.HASAN BASRI NO.57

1

KANTOR CABANG

79281

IKS TELEPON

R02- KANTOR CABANG KOTABARU

NAMA PROVIDER

1500000000845

KANTOR CABANG

NO

:

KODE POS

KODE POS

IKS TELEPON

NO IKS 23791

73221

PIMPINAN TIPE IKS

AWAL IKS

AKHIR IKS

PEMKAB KAPUAS

PER/13/062015

RS.TRAUMA CENTRE

02/03/2016

04/06/2017

UPT PUSKESMAS TANGKILING

PER/04/012016

RS.TRAUMA CENTRE

24/02/2016

22/07/2016

R04- KANTOR CABANG PANGKALAN BUN


SM0480



99 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

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

KANTOR CABANG

NO

KODE PROVIDER

:

S01- KANTOR CABANG SAMARINDA

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-1380214421

PUKESMAS BANTUAS

JL BANTUAS PALARAN

75241

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

2

7-1464240699

PUSKESMAS AIR PUTIH

JL AIR PUTIH SAMARINDA ULU

75122

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

24/02/2016

31/12/2016

3

7-1464311570

PUSKESMAS BAQA

JL BAQA SAMARINDA SEBERANG

75131

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

4

7-1356917662

PUSKESMAS BENGKURING

BENGKURING

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

5

7-1380408843

PUSKESMAS BUKUAN

JL BUKUAN PALARAN

75241

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

6

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

7

7-1359826423

PUSKESMAS JUANDA

JL IR JUANDA SAMARINDA ULU

75122

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

MA11222I


SM0480



100 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

8

7-1507208803

PUSKESMAS KARANG ASAM SAMARINDA

JL KARANG ASAM

75125

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

9

7-1464440551

PUSKESMAS LEMPAKE

JL LEMPAKE SAMARINDA UTARA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

10

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

11

7-1380502014

PUSKESMAS MAKROMAN

JL MAKROMAN PALARAN

75241

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

12

7-1464657234

PUSKESMAS MANGKUPALAS

JL MANGKUPALAS SAMARINDA SEBERANG

75131

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

13

7-1464111057

PUSKESMAS PALARAN

JL PALARAN

75241

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

14

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

15

7-1463967676

PUSKESMAS REMAJA

JL REMAJA SUNGAI PINANG

75117

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

16

7-1464167298

PUSKESMAS SAMBUTAN

JL SAMBUTAN

75114

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

17

7-1461318105

PUSKESMAS SEGIRI

JL SEGIRI SAMARINDA KOT

75111

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

18

7-1380543865

PUSKESMAS SEMPAJA

SEMPAJA SAMARINDA UTARA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

19

7-1465607297

PUSKESMAS SIDOMULYO

JL SIDOMULYO SAMARINDA ILIR

75114

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

MA11222I


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101 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

20

7-1464546252

PUSKESMAS SUNGAI KAPIH

JL SUNGAI KAPIH SAMBUTAN

75114

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

20/01/2016

31/12/2016

21

7-1378835889

PUSKESMAS SUNGAI SIRING

KELURAHAN SUNGAI SIRING SAMARINDA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

22

7-1380635626

PUSKESMAS TEMINDUNG

JL TEMINDUNG SAMARINDA UTARA

75118

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

23

7-1380777307

PUSKESMAS WONOREJO

KELURAHAN WONOREJO

75125

PEMERINTAH

PKS/02/12.2015

RS.TRAUMA CENTRE

12/01/2016

31/12/2016

24

7-1356184197

RSUD I.A MOEIS

JL H.A M.M RIFADDIN

75131

PEMERINTAH

PKS/01/12.2015

RS.TRAUMA CENTRE

11/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

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

PUSKESMAS KAMPUNG BUGIS

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

77311


PER/06/122015

RS.TRAUMA CENTRE

20/01/2016

01/12/2016

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

MA11222I


SM0480



102 / 108 02-03-2016 13:40:34


NO

KODE PROVIDER

:

T00- KANTOR CABANG MANADO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1400000000070

PRAKTEK DR RAUW GEERTJE ADELEIDA

JL TNI 4 NO 53 TIKALA ARES LINGK II MANADO

3357822

DR RAUW G ADELEIDA

PER/008/032016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

2

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

3

1400000000068

RS ROBERT WOLTER MONGISIDI

JLN. 14 FEBRUARI TELING ATAS

876087

DR. ADHY SUGIH ARTO

PER/007/03/2016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

4

1400000000067

RS SITTI MARYAM

JLN. POGIDON RAYA NO. 110 KEC. TUMINTING

851577

DR. ANY RACHMAN

PER/005/032016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

5

1400000000078

RSU PANCARAN KASIH GMIM MANADO

JL SAM RATULANGI XIII MANADO

857629

DR FRANKY V T KAMBEY

PER/004/032016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

6

1500000000352

RUMAH SAKIT BHAYANGKARA MANADO

JALAN SAM RATULANGI NO. 326 MANADO

DRG. IGNATIUS HENDRA ARIFIANTO

PER/009/032016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

7

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

8

1400000000232

RUMAH SAKIT UMUM BETHESDA

JALAN RAYA TOMOHON, KOTA TOMOHON

891020

DR ROBBIN R.F WAROUW

PER/003/072016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

9

1400000000153

RUMAH SAKIT UMUM HERMANA LEMBEAN

JLN. A. MONONUTU DESA LEMBEAN, MINAHASA UTARA

891020

DR. LAURENTIUS RONALD PONTOH

PER/006/032016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

10

1400000000059

RUMKITAL DR. WAHYU SLAMET

JALAN YOS SUDARSO NO. 26 BITUNG

35030

DR. SUJOKO PURNOMO, SP.B

PER/001/022016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

11

1400000000428

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

MA11222I


SM0480



103 / 108 02-03-2016 13:40:34


NO

:

KODE PROVIDER

T01- KANTOR CABANG PALU

NAMA PROVIDER

ALAMAT

1

1400000000290

PUSKESMAS SALAKAN

SALAKAN KABUPATEN BANGGAI KEPULAUAN

2

1400000000054

RSD. MADANI

JL. THALUAKOJI NO. 11 PALU

KANTOR CABANG

NO

:

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1400000000104

RSUD M.M.DUNDA

JLN ACHMAD A. WAHAB NO 53 KEC LIMBOTO

2

1400000000477

RSUD OTANAHA

3

1400000000102

4

1400000000155

MA11222I

:

IKS TELEPON

PIMPINAN NO IKS DR. JAMES HD PINONTOAN

491470

TIPE IKS

AWAL IKS

AKHIR IKS

PER/16/082015

RS.TRAUMA CENTRE

14/01/2016

31/07/2016

PER/002/012016

RS.TRAUMA CENTRE

01/03/2016

28/02/2017

T02- KANTOR CABANG GORONTALO

1

KANTOR CABANG

KODE POS

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

RSUD DR M.M DUNDA

PER/01/012016

RS.TRAUMA CENTRE

10/02/2016

31/12/2017

JL RAMBUTAN NO 413 KEL BULADU KEC KOTA BARAT

RSUD OTANAHA

PER/02/012016

RS.TRAUMA CENTRE

01/03/2016

31/12/2017

RSUD PROF DR. H. ALOEI SABOE

JL PROF DR H ALOEI SABOE KEL WONGKADITI TIMUR

RSUD PROF DR. H. ALOEI SABOE

PER/04/042015

RS.TRAUMA CENTRE

10/02/2016

31/12/2016

RSUD TOTO KABILA

JL KESEHATAN NO 25 DESA PERMATA KEC TILONGKABILA

RSUD TOTO KABILA

PER/05/012016

RS.TRAUMA CENTRE

10/02/2016

31/12/2017

881455

8701943

W00- KANTOR CABANG MAKASSAR


SM0480



104 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1

1400000000044

RS AWAL BROS MAKASSAR

JL. JENDRAL URIP SUMOHARJO NO. 43

2

1500000000111

RSUP DR WAHIDIN SUDIROHUSODO MAKASSAR

JL PERINTIS KEMERDEKAAN KM 11 TAMALANREA

KANTOR CABANG

NO

:

KODE PROVIDER

NAMA PROVIDER

ALAMAT

1400000000293

RS SANTA ANNA KENDARI

JL. DR. MOH HATTA NO 65 A

2

1400000000062

RSUD ABUNAWAS KOTA KENDARI

JL BRIGJEN Z.A SUGIANTO NO.39

3

1400000000381

RSUD KAB KOLAKA (BLUD)

JL.WR SUPRATMAN NO 20

NO

KODE PROVIDER

:

IKS TELEPON

PIMPINAN NO IKS

454567

PT MAKASSAR GLOBAL AWAL BROS

TIPE IKS

AWAL IKS

AKHIR IKS

PER/006/012016

RS.TRAUMA CENTRE

24/02/2016

31/12/2017

PER/003/012016

RS.TRAUMA CENTRE

01/03/2016

04/01/2018

W01- KANTOR CABANG KENDARI

1

KANTOR CABANG

KODE POS

KODE POS

IKS TELEPON

PIMPINAN NO IKS

41916365

32213700

TIPE IKS

AWAL IKS

AKHIR IKS

PT CITRA RATNA NIRMALA

PER/015/022016

RS.TRAUMA CENTRE

22/02/2016

31/01/2017

DINAS KESEHATAN KOTA KENDARI

PER/004/012016

RS.TRAUMA CENTRE

22/02/2016

04/02/2017

DINAS KESEHATAN KOLAKA

PER/002/022016

RS.TRAUMA CENTRE

25/02/2016

08/02/2018

W02- KANTOR CABANG PALOPO

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

1500000000097

DR YAIN PANGGALO

JL PONGTIKU RANTEPAO

255009811

DR YAIN PANGGALO

PER/01/012016

RS.TRAUMA CENTRE

01/03/2016

31/12/2016

2

08339

RS BINTANG LAUT PALOPO

K. H. M KASIM NO. 5

21302

YAYASAN RATNA MIRIAM

PER/12/032015

RS.TRAUMA CENTRE

25/02/2016

29/02/2016

MA11222I


SM0480



105 / 108 02-03-2016 13:40:34


NO

1

KODE PROVIDER

W21- KABUPATEN SINJAI

NAMA PROVIDER

7-2015740298

KANTOR CABANG

NO

:

RSUD SINJAI

:

KODE PROVIDER

ALAMAT

JLN JEND SUDIRMAN NO. 47 SINJAI

KODE POS

92611

IKS TELEPON

NO IKS 048221132

NAMA PROVIDER

ALAMAT

KODE POS

RS.TRAUMA CENTRE

16/02/2016


PIMPINAN NO IKS

RS SURYA HUSADHA DENPASAR

JL PULAU SERANGAN NO 7 DENPASAR

2

1400000000483

RS SURYA HUSADHA UBUNG

JL COKROAMINOTO NO 356

3

1200000000017

RSU BHAKTI RAHAYU DENPASAR

JL GATOT SUBROTO II NO 11 DENPASAR

430270

4

1400000000554

RSU PARAMA SIDHI

JLN. AHMAD YANI NO. 171A SINGARAJA

5

1400000000482

RSU SURYA HUSADHA NUSA DUA

6

1400000000485

SILOAM HOSPITAL BALI

MA11222I

PER/002/012016

AWAL IKS

IKS TELEPON

1400000000484

:

PEMERINTAH DAERAH KAB SINJAI

TIPE IKS

X00- KANTOR CABANG BALI DENPASAR

1

KANTOR CABANG

PIMPINAN

TIPE IKS

AWAL IKS

AKHIR IKS

PER/02/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

PER/01/2016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

PER/05/012016

RS.TRAUMA CENTRE

05/01/2016

31/12/2016

32701

PER/06/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

JL SILIGITA BLOK I NO 14 NUSA DUA

766154

PER/03/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

JALAN SUNSET ROAD NO 818 KUTA

779900

PER/04/012016

RS.TRAUMA CENTRE

08/01/2016

31/12/2016

233787

PUTU IVAN YUNATANA

X01- KANTOR CABANG KUPANG


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106 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-2064672333

KILNIK KUPANG GRAHA MEDIKA

JALAN BUNDARAN PU NOMOR 54C KUPANG

85111

85852420

PT. KUPANG GRAHA MEDIKA

PER/ 008/ 022016

RS.TRAUMA CENTRE

18/02/2016

17/02/2017

2

1400000000288

RS BHAYANGKARA KUPANG

JL NANGKA 84 KUPANG

85111

821999

POLRI / POLDA NTT

PER/ 017/ 102015

RS.TRAUMA CENTRE

22/01/2016

31/12/2016

3

1400000000417

RSUD DR TC HILLERS MAUMERE

JALAN WAIRKLAU MAUMERE

PER/ 005/ 012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

4

1500000000064

RSUD KAB SABU RAIJUA

JALAN TRANS SEBA BOLOU KM 7 MENIA SABU

PER/ 011/ 02016

RS.TRAUMA CENTRE

24/02/2016

24/02/2017

5

1400000000565

RSUD MGR GABRIEL MANEK ATAMBUA

JALAN DR SOETOMO NO 02 ATAMBUA

21016

PER/ 003/ 012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

6

1400000000394

RSUD UMBU RARA MEHA WAINGAPU

JALAN ADAM MALIK NO 54 WAINGAPU

61302

PER/ 007/ 012016

RS.TRAUMA CENTRE

01/02/2016

30/01/2017

7

7-2240138189

RUMAH SAKIT KRISTEN LINDI MARA

JALAN PROF WZ YOHANNES NOMOR 06

YUMERKRIS

PER 010/ 022016

RS.TRAUMA CENTRE

24/02/2016

24/02/2017

8

1500000000119

RUMAH SAKIT PANGKALAN TNI AU EL TARI

JL ADI SUCIPTO NO 2 KUPANG

TNI AU

PER/ 004/ 012016

RS.TRAUMA CENTRE

28/01/2016

31/12/2016

9

1400000000543

RUMAH SAKIT PENYANGGA PERBATASAN BETUN

JALAN SUKABIHANAWA DESA KAMANASA MALAKA TENGAH

PER/ 09/ 022016

RS.TRAUMA CENTRE

15/02/2016

09/02/2017

10

7-1708103837

SILOAM HOSPITALS LABUAN BAJO

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

PER/ 006/ 012016

RS.TRAUMA CENTRE

29/01/2016

29/01/2017

KANTOR CABANG

MA11222I

:

2426133

87111

3838123

86754

PT LINTAS BUANA JAYA

X03- KANTOR CABANG MATARAM


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107 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

PIMPINAN NO IKS

TIPE IKS

AWAL IKS

AKHIR IKS

1

7-2053953083

RS H.L. MANAMBAI ABDULKADIR

JL LINTAS SUMBAWA-BIMA KM 5 KAB SUMBAWA BESAR

84311

803801361

DR H SYAMSUL HIDAYAT

PER/21/122015

RS.TRAUMA CENTRE

18/02/2016

31/12/2016

2

7-2305763363

RSUD DR R SOEDJONO SELONG

JL PROF M YAMIN NO 55 SELONG KAB LOMBOK TIMUR

83611

863445444

DR H KARSITO SPPD

PER/23/102015

RS.TRAUMA CENTRE

01/03/2016

31/12/2016

3

7-2043435163

RSUD KOTA MATARAM

JALAN BUNG KARNO NO 3 PAGUTAN MATARAM

83117

907545167

DR H.L. HERMAN MAHAPUTRA MKES

PER/02/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

4

7-2055355604

RSUD PRAYA

JL H LALU HASYIM NO 02 KEL TIWU GALI KEC PRAYA KAB LOMBOK TENGAH

83511

75786619

DR MUZAKIR LANGKIR

PER/22/112015

RS.TRAUMA CENTRE

18/02/2016

31/12/2016

5

7-2094061443

RSUD PROVINSI NTB

JL PRABURANGKASARI DASAN CERMEN MATARAM

83117

081854700 5

DR H MAWARDI HAMRY MPPM

PER/01/012016

RS.TRAUMA CENTRE

23/02/2016

31/12/2016

6

7-2306934144

RSUD SUMBAWA

JL GARUDA NO 5 SUMBAWA BESAR

84311

909048313

DR SELVI

PER/04/012016

RS.TRAUMA CENTRE

01/01/2016

31/12/2016

KANTOR CABANG

NO

KODE PROVIDER

:

X04- KANTOR CABANG BALI GIANYAR

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

AWAL IKS

AKHIR IKS

RS.TRAUMA CENTRE

22/01/2016

31/12/2016

21172

PER/005/012016

RS.TRAUMA CENTRE

22/01/2016

31/12/2016

943049

PER/003/012016

RS.TRAUMA CENTRE

22/01/2016

31/12/2017

1500000000114

KLINIK PENTA MEDIKA

JL. RAYA MANGGIS 88

41909

2

1400000000473

RSUD KLUNGKUNG

JL. FLAMBOYAN NO 40 SEMARAPURA

3

1400000000321

RSUD SANJIWANI GIANYAR

JL. CIUNG WANARA NO. 2

DR. A A GEDE YUDI YUNARDHANA PUTRA

TIPE IKS

PER/006/012016

1

MA11222I

PIMPINAN


SM0480



108 / 108 02-03-2016 13:40:34

Periode : 01012016 s/d 31122016

NO

KODE PROVIDER

NAMA PROVIDER

ALAMAT

KODE POS

IKS TELEPON

NO IKS

4

1400000000321

RSUD SANJIWANI GIANYAR

JL. CIUNG WANARA NO. 2

943049

5

1200000000003

RUMAH SAKIT UMUM GANESHA

JL RAYA CELUK,SUKAWATI

298233

MA11222I

PIMPINAN

DR. GUSTI PUTU DARMIKA.S.KED

TIPE IKS

AWAL IKS

AKHIR IKS

ADD/004/082015

RS.TRAUMA CENTRE

18/01/2016

31/12/2016

PER/002/012016

RS.TRAUMA CENTRE

18/01/2016

31/12/2016


SM0480

DAFTAR JEJARING TRAUMA CENTER DAN FASILITAS KERJASAMA BPJS KETENAGAKERJAAN

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