Tanggal Cetak :
Waktu Cetak :
1 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000057
DR. CHRISTOFFEL
RELMASIRA
351654
DR. CHRISTOFFEL
RELMASIRA
PER/011/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1500000000317
RS BERGERAK TIAKUR
081343343
290
PER/004/032015
RS.TRAUMA
CENTRE
01/04/2015
30/03/2016
1500000000219
RS BHAYANGKARA POLDA
MALUKU
349450
POLDA MALUKU
PER/001/022015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2017
1400000000084
21638
PER/012/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1400000000056
RS HATIVE PASSO
362512
PER/008/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1400000000042
RST TK II DR J.A.
LATTUMETEN
JL DR TAMAELA AMBON
353555
KODAM PATTIMURA
PER/009/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1400000000076
343848
YAYASAN WAKAF AL
FATAH
PER/013/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1400000000041
RSUD DR M HAULUSSY
JL KAYADOE AMBON
PER/010/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1500000000818
RSUD NAMROLE
JL KAMBOJA
PER/014/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
10
1500000000539
RSUD PIRU
JL ARTERI PIRU
DR MICHEL A
SIWABESSY
PER/006/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
11
1500000000620
RSUD PP MAGRETI
PEMKAB MTB
PER/007/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
12
7-141557413
DR . HISNINDARSYAH
001-000112015
RS.TRAUMA
CENTRE
24/11/2015
31/10/2017
MA11222I
00000
SM0480
Halaman :
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2 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1400000000043
DR. TUTHANURANII
NACHRAWY, M. KES
1500000000215
JL PAHLAWAN REVOLUSI NO 5
1300000000005
1500000000625
RSUD JAILOLO
05392
RSUD TOBELO
05392
RSUD TOBELO
08186
1500000000050
1500000000050
10
1500000000050
11
12
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
DR.TUTHANURANI
NACHRAWY
PER/003/042015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
3121951
DR.SUTOMO RAHARJO,
SP.A
PER/002/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
3121281
PEMDA
PER/001/022015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PEMDA HALBAR
PER/010/012015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
21566
PEMKAB HALUT
PER/07/0032015
FFS
01/04/2015
31/03/2016
21566
PEMKAB HALUT
PER/007/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PEMDA TIDORE
KEPULAUAN
FFS
01/05/2015
30/04/2016
3121623
PER/003/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
3121623
PER/03/122014
FFS
01/01/2015
31/12/2015
3121623
PER/003/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000035
PER/004/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000035
PER/001/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
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3 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000036
JL AIS NASUTION NO 2
TNI
PER/009/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
14
1500000000296
JL RAYA WEDA
PEMDA HALTENG
PER/006/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
15
1500000000295
PEMDA HALMAHERA
TIMUR
PER/005/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-136408795
APOTIK KLABOT
JLN SORONG
98451
RINI
123456
RS.TRAUMA
CENTRE
22/10/2015
01/12/2016
7-136432885
BUKIT
98451
MR. BUKIT
12546244764564
894
RS.TRAUMA
CENTRE
22/10/2015
22/10/2016
1500000000503
YULIANTI
MATANDUNG,S.SOS,MM
PER/37/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
7-136432856
KLINIK AQILLA
JL MALANU
YOGI
15455421021511
51
RS.TRAUMA
CENTRE
22/10/2015
22/10/2016
1400000000012
DR LIDIA KURNIAWAN
PER/018/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1400000000555
PER/044/122015
RS.TRAUMA
CENTRE
05/01/2016
30/11/2016
MA11222I
322549
98451
13351490
SM0480
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4 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000384
PUSKESAMAS SAYOSA
48060504
PER/031/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1500000000383
54285228
PER/032/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1500000000434
54173183
PER/030/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
10
1500000000435
PUSKESMAS KLAFDALIM
(KTC)
54173183
PER/023/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
11
1500000000386
PUSKESMAS KLAMONO
(KTC)
1060944
PER/028/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
12
1500000000382
PUSKESMAS KLASOUW
(KTC)
44468629
PER/0034/03201
5
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
13
1500000000376
62003121
PER/033/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
14
1500000000380
47330915
PER/036/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
15
1500000000390
PUSKESMAS MAJARAN
(KTC)
MAJARAN MARIYAI SP 2
44086493
PER/021/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
16
1500000000388
99373405
PER/024/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
17
1500000000391
PUSKESMAS MALAWILI
44181510
PER/019/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
18
1500000000379
MARIYAI SP 2
39495966
PER/ 020/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
MA11222I
SM0480
Halaman :
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5 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
19
1500000000378
MARIYAI SP 2
39495966
PER/020/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
20
1500000000381
54691544
PER/035/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
21
1500000000389
PUSKESMAS MAYAMUK
(KTC)
44419198
PER/022/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
22
1500000000385
PUSKESMAS MEGA
97935870
PER/029/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
23
1500000000387
PUSKESMAS SAILOLOF
19764619
PER/027/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
24
1500000000436
44070654
PER/025/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
25
1500000000377
3199503
PER/026/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
26
1500000000592
RS HERLINA (RSTC)
JL SELAT MAKASSAR NO 7
4852341
IR HERLINA SIHOMBING
PER/040/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
27
04658
RS MUTIARA
JL MALEO NO 2 SORONG
095132743
3
DR HJ
PAHIMAH/ISKANDAR
PER/001/012016
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
28
1500000000104
RS MUTIARA SORONG
(RSTC)
327433
DR HJ PAHIMA
ISKANDAR
PER/018/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
29
1500000000551
RS PERTAMINA SORONG
(RSTC)
44440220
PER/039/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
30
1400000000022
PER/038/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
MA11222I
SM0480
Halaman :
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Waktu Cetak :
6 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
31
1400000000408
JL DISTRIK WAISAI
44717931
PER/043/112015
RS.TRAUMA
CENTRE
01/02/2016
31/10/2016
32
1400000000034
JL KESEHATAN NO 36
321763
PER/41/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
33
1500000000080
7705545
PEMDA SORONG
SELATAN
PER/016/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2016
34
1500000000101
8460538
PER/042/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000501
1500000000457
1500000000455
RS BHAYANGKARA
1500000000524
1400000000375
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/11/032015
RS.TRAUMA
CENTRE
18/03/2015
17/03/2016
KLINIK PRATAMA
BUNDA HATI KUDUS
PER/10/0315
RS.TRAUMA
CENTRE
18/03/2015
17/03/2016
RS BHAYANGKARA
PER/08/022015
RS.TRAUMA
CENTRE
26/02/2015
25/02/2017
RS BUNDA PENGHARAPAN
MERAUKE
RS BUNDA
PENGHARAPAN
MERAUKE
PER/ 09/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
YAYASAN RS DIAN
HARAPAN
PER/15/092015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
44603533
572123
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
7 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
RSMI JAYAPURA
PER/18/122015
RS.TRAUMA
CENTRE
14/01/2016
31/12/2016
522958
PER/19/122015
RS.TRAUMA
CENTRE
14/01/2016
31/12/2016
321512
PER/16/112015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
RSUD ABEPURA
PER/ 12/042015
RS.TRAUMA
CENTRE
01/04/2015
01/04/2016
44976339
RSUD KABUPATEN
SUPIORI
PER/14/042015
RS.TRAUMA
CENTRE
01/04/2015
30/04/2016
081148803
0
RSUD KWAINGGA
KEEROM
PER/07/022015
RS.TRAUMA
CENTRE
25/02/2015
24/02/2016
RSUD MERAUKE TC
085244682
879
RSUD MERAUKE
PER/16/112015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
1500000000456
RSUD YOWARI
085244906
298
RSUD YOWARI
PER/09/022015
RS.TRAUMA
CENTRE
25/02/2015
24/05/2016
1500000000828
44265612
RUMKITAL DR. R
GANDHI A.T BIAK
PER/13/042015
RS.TRAUMA
CENTRE
01/04/2015
29/04/2016
1500000000081
RS MARTHEN INDEY
1400000000716
1400000000514
RSAL MERAUKE TC
1500000000525
RSUD ABEPURA
10
1500000000829
11
1500000000454
12
1400000000515
13
14
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
8 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
TIPE IKS
AWAL IKS
AKHIR IKS
31/12/2015
RSUD NABIRE
PER/03/032015
RS.TRAUMA
CENTRE
01/03/2015
28/03/2016
YAYASAN CARITAS
PER/02/022015
RS.TRAUMA
CENTRE
01/02/2015
29/02/2016
RSUD MIMIKA
PER/07/032015
RS.TRAUMA
CENTRE
01/04/2015
30/04/2016
1500000000258
1500000000174
1500000000345
KODE PROVIDER
NO IKS
01/01/2015
NO
PIMPINAN
RS.TRAUMA
CENTRE
1400000000573
IKS
TELEPON
PER/013/122014
KANTOR CABANG
KODE
POS
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000446
KLINIK HUSADA
31120
JAMALUDDIN
PER/10/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000000228
KLINIK LHOKSEUMAWE
HUSADA
081396697
999
PER/04/022015
RS.TRAUMA
CENTRE
13/02/2015
12/02/2016
1500000000125
085277907
770
H. IRSYAD H. ABDULLAH
PER/01/012015
RS.TRAUMA
CENTRE
02/01/2015
01/01/2016
1500000000229
AZHARI
PER/19/122014
RS.TRAUMA
CENTRE
02/01/2015
01/01/2016
1500000000225
AZHARI
PER/20/122014
RS.TRAUMA
CENTRE
02/01/2015
01/01/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
9 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000630
7-1092257715
1500000000127
1500000000406
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
441/211/PKM/20
15
RS.TRAUMA
CENTRE
21/04/2015
20/04/2016
064321396
PER/25/102015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
22887
DR.FAISAL,SP.OG
PER/02/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
48713
HJ HERAWATI
PER/05/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
24511
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000167
637433
PEMERINTAH ACEH
PER/08/022015
RS.TRAUMA
CENTRE
04/02/2015
03/02/2016
1400000000569
CEMPAKA LIMA
33345
HJ. KARTINI.N.I
PER/38/122015
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
1500000000056
KLINIK AA MEDICAL
PER/03/012015
RS.TRAUMA
CENTRE
07/01/2015
06/01/2016
1400000000566
KLINIK ATHARI
PER/37/122015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
1500000000122
DR.BUDI PERMANA
PER/06/012015
RS.TRAUMA
CENTRE
28/01/2015
27/01/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
10 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000122
DR.BUDI PERMANA
PER/08/022016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
1500000000055
PER/04/012016
RS.TRAUMA
CENTRE
27/01/2016
31/12/2016
1500000000153
M. BAGUS ANDREAS
TAUFANI, S.FARM, APT
PER/07/012015
RS.TRAUMA
CENTRE
03/02/2015
02/02/2016
1500000000019
KLINIK LATIFAH
PER/01/012015
RS.TRAUMA
CENTRE
06/01/2015
05/01/2016
10
1500000001919
AZIZURRAHMAN,
SKM,MM
PER/24/072015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
11
1500000000105
KLINIK NABILA
33555
DR. RACHMI
KURNIAWATI
PER/04/012015
RS.TRAUMA
CENTRE
16/01/2015
15/01/2016
12
7-1676350253
72303666
PER/05/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
13
1500000000242
MINALTIWATI, AMD.KEB
PER/13/022105
RS.TRAUMA
CENTRE
27/02/2015
26/02/2016
14
1500000000569
PIUSKESMAS MONTASIK
PER / 19.16 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
15
1500000000555
PUSKEMAS LHOKNGA
DINAS KESEHATAN
ACEH BESAR
PER / 19.02 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
16
1500000000561
PUSKEMAS SEULIMUM
PER / 19.07 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
17
1500000000567
PUSKESMAS BAITUSSALAM
PER / 19.14 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
21536
23111
23352
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
11 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
18
1500000000581
PUSKESMAS BLANG
BINTANG
19
1500000000576
PUSKESMAS DARUL
IMARAH
20
1500000000577
21
1500000000566
22
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER / 19.28 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER / 19.23 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER / 19.23 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PUSKESMAS DARUSSALAM
PER / 19.13 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000000560
PUSKESMAS IE ALANG
PER / 19.07 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
23
1500000000557
PUSKESMAS INDRAPURI
PER / 19.04 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
24
1500000000571
PER / 19.18 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
25
1500000000563
PER / 19.10 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
26
1500000000572
PUSKESMAS KRUENG
BARONA JAYA
PER / 19.19 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
27
1500000000568
PER / 19.15 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
28
1500000000559
PER / 19.06 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
29
1500000000574
PER / 19.21 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
48375
2790
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
12 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
30
1500000000579
PUSKESMAS LAMPISANG
PER / 19.26 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
31
1500000000558
PUSKESMAS LAMPUPOK
PER / 19.04 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
32
1500000000562
PUSKESMAS LAMTEUBA
PER / 19.09 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
33
1500000000564
PUSKESMAS LEMBAH
SEULAWAH
PER / 19.11 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
34
1500000000556
PUSKESMAS LEUPUNG
PER / 19.03 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
35
1500000000554
PUSKESMAS LHOONG
DINAS KESEHATAN
ACEH BESAR
PER / 19.01 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
36
1500000000565
PER / 19.12 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
37
1500000000578
PER / 19.25 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
38
1500000000570
PUSKESMAS PIYEUNG
JLN AYAHANDA
PER / 19.17 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
39
1500000000580
PER / 19.27 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
40
1500000000575
PER / 19.22 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
41
1500000000573
PUSKESMAS SUKAMAKMUR
PER / 19.20 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
7400250
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
13 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
42
1400000000191
96707970
DR JULIANA SP AK
PER/28/092015
RS.TRAUMA
CENTRE
12/01/2016
01/09/2016
43
1400000000073
RS HARAPAN BUNDA
48114
PER/15/032015
RS.TRAUMA
CENTRE
25/02/2015
24/02/2016
44
1500000001060
PER / 20/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
45
1500000001923
RSUD MEURAXA
43097
PEMERINTAH KOTA
BANDA ACEH
RS.TRAUMA
CENTRE
18/08/2015
17/08/2017
46
1500000000093
085238105
999
DIANA PURWANI
PER/36//12/2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
47
1500000000124
RUMAH SAKIT
MALAHAYATI
32874
YAYASAN RS
MALAHAYATI
PER/05/012015
RS.TRAUMA
CENTRE
16/01/2015
15/01/2016
48
1400000000194
44114
PER/34/122015
RS.TRAUMA
CENTRE
12/01/2016
01/01/2017
49
1400000000194
44114
PER/23/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
50
1400000000570
7555750
PER/35/122015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
51
1500000000302
HERI RISWANDI
PER/16/ 032015
RS.TRAUMA
CENTRE
02/03/2015
01/03/2016
52
1500000000166
RUMKIIT BHAYANGKARA
KEPOLISIAN REPUBLIK
INDONESIA
PER/09/022015
RS.TRAUMA
CENTRE
05/02/2015
04/02/2016
KANTOR CABANG
MA11222I
23111
41470
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
14 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000546
20354
PER/02/012016
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
1400000000552
085336187
3663
DR H SYAFRIRUDDIN,
MM
PER/17/012016
RS.TRAUMA
CENTRE
27/01/2016
31/12/2016
1500000000039
085275453
457
COCO ARMANSYAH,
SKM
PER/12/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000037
PUSKESMAS BANDAR
PUSAKA
085363910
858
SYAMSUDDIN, SKM
PER/14/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000037
PUSKESMAS BANDAR
PUSAKA
085363910
858
SYAMSUDDIN, SKM
PER/04/012016
RS.TRAUMA
CENTRE
21/01/2016
31/12/2017
1500000000023
PUSKESMAS BENDAHARA
KECAMATAN BENDAHARA
085277213
585
RADHIYAH, SKM
PER/02/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
1500000000024
085276981
936
PER/05/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
1500000000042
PUSKESMAS KEJURUAN
MUDA
085275231
971
PER/09/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000043
085272110
394
IDA IRAWATI
PER/08/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
10
1500000000398
PUSKESMAS LANGSA
BARAT
23093
PER/16/022015
RS.TRAUMA
CENTRE
02/02/2015
31/12/2015
11
1500000000396
SAFRITA, SKM
PER/17/022015
RS.TRAUMA
CENTRE
02/02/2015
31/12/2015
12
1500000000522
PER/15/022015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
MA11222I
69222267
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
15 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000395
PER/19/022015
RS.TRAUMA
CENTRE
02/02/2015
31/12/2015
14
1500000000397
DR. MAHLIDAYANTI
PER/18/022015
RS.TRAUMA
CENTRE
02/02/2015
31/12/2015
15
1500000000022
PUSKESMAS MANYAK
PAYED
085358091
334
DR. FITRIYANTI
PER/01/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
16
1500000000045
PUSKESMAS RANTAU
KECAMATAN RANTAU
081260441
263
DR TSUAIBAHTUL
ASLAMIYAH NASUTION
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
17
1500000000044
085260746
332
PER/07/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
18
1500000000040
PUSKESMAS SEKERAK
KECAMATAN SEKERAK
082168103
036
PER/11/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
19
1500000000040
PUSKESMAS SEKERAK
KECAMATAN SEKERAK
082168103
036
PER/03/012016
RS.TRAUMA
CENTRE
21/01/2016
31/12/2017
20
1500000000026
PUSKESMAS SERUWAY
KECAMATAN SERUWAY
085270118
101
JAMILAH, SKM
PER/04/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
21
1500000000038
081265193
134
DR. SANDY
PRAMAYUDHA
PER/13/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1500000000025
081263173
69
IRWANUDDIN, SKM
PER/03/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
23
1500000000041
PUSKESMAS TAMIANG
HULU
081161333
19
PER/10/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
1400000000340
23071
IR EDDY PURNOMO
PER/01/012016
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
16 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1400000000340
23071
IR EDDY PURNOMO
PER/06/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
1400000000340
23071
IR EDDY PURNOMO
PER/25/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
27
1400000000675
22228
DR YUSUF, MM
PER/10/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
28
1400000000675
22228
DR YUSUF, MM
PER/01/012016
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
29
1500000000034
22051
DR. HERMAN I
PER/11/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
30
1500000000034
22051
DR. HERMAN I
PER/18/012016
RS.TRAUMA
CENTRE
27/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000612
23611
DR. MARHABAN
PER/08/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000610
23611
AMIR HIDAYAT, ST
PER/07/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000613
PER/12/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
17 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/13/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23662
AJA PUTRI
PER/03/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23662
DR, CHAIDIR
PER/20/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
PUSKESMAS BEUTONG
23672
HJ. NURLIMPAH
PER/10/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000004
PUSKESMAS BEUTONG
ATEUH
23672
PER/39/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
1500000000010
23671
PER/09/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1400000000631
PUSKESMAS COT
SEUMEREUNG ACEH BARAT
23652
DR. SUSANTI
PER/21/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
11
1400000000630
PUSKESMAS DRIEN
RAMPAK ACEH BARAT
23652
MUHAMMAD NASIR,SKM
PER/31/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
12
1500000000008
PUSKESMAS JEURAM
23671
NURZAINI
PER/33/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
13
1400000000646
PUSKESMAS JOHAN
PAHLAWAN ACEH BARAT
23615
PER/22/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
14
1400000000615
PUSKESMAS KAJEUNG
ACEH BARAT
23681
ZULHAMDI ,AMK
PER/27/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
15
1500000000005
23661
DARMANSYAH,S.ST
PER/18/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000611
1500000000012
1500000000002
1500000000013
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
18 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1400000000629
23652
SALMAN RUSLI,
SKM.,M.EPID
PER/30/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
17
1500000000003
PUSKESMAS LUENG
KEUBEU JAGAT
23662
PER/19/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
18
1400000000621
PUSKESMAS MEUREUBO
ACEH BARAT
23615
PER/23/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
19
1400000000616
PUSKESMAS MEUTULANG
ACEH BARAT
23681
HASANUDDIN D, SE
PER/26/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
20
1500000000006
PUSKESMAS PADANG
PANJANG
23661
PER/05/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21
1500000000011
PUSKESMAS PADANG
RUBEK
23661
PER/04/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
22
1400000000617
PUSKESMAS PANTE
CEUREUMEN
23681
MUHAMMAD AMIN, SE
PER/25/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
23
1400000000618
PUSKESMAS PEUREUMUE
ACEH BARAT
23681
PER/24/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
24
1400000000623
23682
PER/32/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
25
1400000000623
23682
PER/28/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1500000000007
23661
SITI ROMLAH
PER/34/12215
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
27
1400000000648
23615
PER/28/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
19 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
28
1500000000001
23662
PER/37/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
29
1500000000016
PUSKESMAS TANGKEH
23682
PER/35/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
30
1500000000009
PUSKESMAS UJONG
FATIHAH
23661
CUT NIH
PER/38/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
31
1500000000014
23671
HJ. YUSNIDAR
PER/36/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
32
1400000000624
23654
YESWARDI, SKM
PER/29/122015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
33
08465
RSU MONTELLA
PER/02/092015
RS.TRAUMA
CENTRE
31/12/2015
31/08/2016
34
1500000000246
PER/06/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
35
1400000000379
SYARIFAH MERI
MERDIANA, S.SI.,APT
PER/02/092015
RS.TRAUMA
CENTRE
31/12/2015
31/08/2016
36
1500000000245
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
37
1500000000245
PER/17/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
38
1400000000273
21137
PER/01/062015
RS.TRAUMA
CENTRE
29/12/2015
30/06/2016
39
1500000000136
RSUD DR H YULIDDIN
AWAY
323615
PER/43/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
77999012
23615
23616
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
20 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
40
1500000000136
RSUD DR H YULIDDIN
AWAY
323615
PER/14/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
41
1500000000123
RSUD KOTA
SUBULUSSALAM
62731700
PEMKOT
SUBULUSSALAM
PER/44/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
42
1500000000123
RSUD KOTA
SUBULUSSALAM
62731700
PEMKOT
SUBULUSSALAM
PER/15/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
43
1400000000602
2210322
PER/06/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
44
1500000000015
92522
DARUSMAN, M.KES
(MMR)
PER/11/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
45
1400000000614
PER/16/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
23654
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000127
BP HARAPAN BUNDA
7852636
NETTY BARITA, SE
PER/21/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000127
BP HARAPAN BUNDA
7852636
NETTY BARITA, SE
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000127
BP HARAPAN BUNDA
7852636
NETTY BARITA, SE
PER/13/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
21 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000065
BP HARAPAN BUNDA 1
6504129
NETTY BARITA,SE
PER/07/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
1500000000065
BP HARAPAN BUNDA 1
6504129
NETTY BARITA,SE
PER/22/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000066
BP HARAPAN BUNDA 3
NETTY BARITA SE
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000066
BP HARAPAN BUNDA 3
NETTY BARITA SE
PER/11/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
1500000000201
BP KURNIA
850915
TAN ERFI
PER/21/022015
RS.TRAUMA
CENTRE
18/02/2015
17/02/2016
1500000000199
JL DARUSSALAM NO 5A
4153169
DR H SAYID BUDHI
PER/13/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
10
1500000000198
7383103
DR SAYID BUDHI
PER/14/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
11
1500000000196
KLINIK AKSARA
97374384
TEGUH SUHARTO, SE
PER/16/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
12
1500000000206
KLINIK AVIATI 1
6103683
PER/09/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
13
1500000000207
KLINIK AVIATI 3
3436450
PER/10/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
14
1500000000203
4155528
PER/11/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
15
1500000000202
80030330
DR RIYADH IKHSAN
PER/12/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
22 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1500000000194
KLINIK BERSAMA
68272131
SAMPE REZEKI, SE
PER/15/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
17
1400000000126
7863134
DR YUDHA PRAYOGI
PER/02/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
18
1400000000126
7863134
DR YUDHA PRAYOGI
PER/20/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
19
1500000000195
97374384
TEGUH SUHARTO,SE
PER/17/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
20
1500000000189
KLINIK MADANI
7032626
PER/12/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
21
1500000000189
KLINIK MADANI
7032626
PER/08/012015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
22
1500000001611
KLINIK MILLENIUM
63792195
SRI REZEKI SE
PER/27/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
23
1500000000197
8219006
PER/23/022015
RS.TRAUMA
CENTRE
18/02/2015
17/02/2016
24
1500000000270
PUSKESMAS AMPLAS
JL SM RAJA
7862798
PER/25/022015.0
1
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
25
1500000000271
PUSKESMAS BESTARI
4150066
PER/25/022015.0
2
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
26
1500000000280
PUSKESMAS DARUSSALAM
JL DARUSSALAM
PER/25/022015.0
3
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
27
1500000000279
JL BINJAI KM 7.5
PER/02/2015.04
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
MA11222I
5237868
SM0480
Halaman :
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Waktu Cetak :
23 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/25/022015.0
5
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
PER/25/022015.0
8
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
PER/25/022015.0
6
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
JL AMALIUN
PER/25/022015
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
JL KARYA DHARMA
PER/25/022015.0
9
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
1500000000273
PUSKESMAS MEDAN
POLONIA
JL POLONIA
PER/25/022015.1
0
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
34
1500000000272
PUSKESMAS MEDAN
SUNGGAL
SUNGGAL
PER/25/022015.1
1
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
35
1500000000269
PUSKESMAS PADANG
BULAN
JL JAMIN GINTING
PER/25/022015.1
2
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
36
1500000000268
HM JONI
PER/25/022015.1
3
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
37
1500000000267
PUSKESMAS PB SELAYANG
II
PER/25/022015.1
4
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
38
1500000000266
PUSKESMAS RANTANG
RANTANG
PER/25/022015.1
5
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
39
1500000000265
PUSKESMAS SIMALINGKAR
JL BAWANG RAYA
PER/25/022015.1
6
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
28
1500000000278
PUSKESMAS HELVETIA
29
1500000000275
PUSKESMAS KAMPUNG
BARU
30
1500000000277
KEDAI DURIAN
31
1500000000276
32
1500000000274
33
MA11222I
8451226
7032005
SM0480
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24 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
40
1500000000264
PUSKESMAS SIMPANG
LIMUN
JL KEMIRI
PER/25/022015.1
7
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
41
1500000000263
PUSKESMAS SUKARAMAI
JL DENAI
PER/25/022015.1
8
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
42
1500000000262
PUSKESMAS TELADAN
JL SM RAJA
PER/25/022015.1
9
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
43
1500000000261
PUSKESMAS TUNTUNGAN
JL BUNGA MELATI
PER/25/022015.2
0
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
44
1500000000191
RS ADVENT MEDAN
4524875
YAYASAN RS ADVENT
MEDAN
PER/19/022015
RS.TRAUMA
CENTRE
16/02/2015
15/02/2016
45
1500000000190
RS BHAYANGKARA MEDAN
8215990
POLDA SUMUT
PER/18/022015
RS.TRAUMA
CENTRE
12/02/2015
11/02/2016
46
1500000000077
RS ESTOMIHI
JL SISINGAMANGARAJA NO 235
7861771
PER/17/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
47
1400000000125
RS ESTOMIHI
7861771
DR. M. SAMOSIR,SP.PD
PER/17/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
48
1500000000077
RS ESTOMIHI
JL SISINGAMANGARAJA NO 235
7861771
PER/09/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
49
1400000000129
RS ISLAM MALAHAYATI
4518766
YAY RS MALAHAYATI
PER/16/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
50
1400000000129
RS ISLAM MALAHAYATI
4518766
YAY RS MALAHAYATI
PER/03/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
51
1500000000208
RS MARTHA FRISKA
MULTATULI
4149666
PT KARYA UTAMA
SEHAT SEJAHTERA
PER/20/022015
RS.TRAUMA
CENTRE
16/02/2015
15/02/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
25 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
88813182
PER/56/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
88881900
PT GRAMARI PRIMA
NUSA
PER/15/012016
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
8475111
PER/06/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
8475111
PER/07/012015
RS.TRAUMA
CENTRE
19/01/2015
31/12/2015
1500000000091
4510766
YAY TD PARDEDE
FOUNDATION
PER/04/012015
RS.TRAUMA
CENTRE
15/01/2015
31/12/2015
57
1500000000091
4510766
YAY TD PARDEDE
FOUNDATION
PER/05/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
58
1500000000624
RSU MATERNA
4514222
PT RUMAH SAKIT
MATERNA
PER/58/042015
RS.TRAUMA
CENTRE
23/04/2015
22/04/2016
59
1400000000124
7875967
PER/18/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
60
1400000000124
7875967
PER/04/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
61
1500000000090
JL MONGONSIDI NO 11 MEDAN
4512687
PER/06/012015
RS.TRAUMA
CENTRE
19/01/2015
31/12/2015
62
1500000000090
JL MONGONSIDI NO 11 MEDAN
4512687
PER/10/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
63
1400000000123
8451812
PER/19/122014
RS.TRAUMA
CENTRE
01/02/2015
52
1500000000537
RS ROYAL PRIMA
JL AYAHANDA NO 68 A
53
7-1446503984
54
1500000000089
55
1500000000089
56
MA11222I
20111
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
26 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
64
1500000000092
8451812
PER/08/122015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
65
1500000000092
8451812
PER/19/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
66
1500000000200
4147646
YAYASAN VINA
ESTETICA
PER/22/022015
RS.TRAUMA
CENTRE
18/02/2015
17/02/2016
67
1500000001551
8364581
KEMENTERIAN
KESEHATAN RI
PER/57/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
68
7-1375319217
DR OTMAN SIREGAR
SPOT
PER/14/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
20122
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000051
BPS SERASI
28756
TAN ERFI
PER/34/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
1400000000051
BPS SERASI
28756
TAN ERFI
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000249
KLINIK AINON
6205667
PER/20/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1500000001829
KLINIK BERSAMA
JL MERDEKA NO.47/67
70532010
DR.TIORI RORIA
MAGDALENA
PER/26/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
21111
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
27 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000291
KLINIK KASIH
72908220
PER/21/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1500000000148
KLINIK KELUARGA
JL MEDAN NO.18 KM 4
28951
IR.AGUSTINUS SIANIPAR
PER/16/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
1400000000553
KLINIK MURNI
6204978
APRIMO MP SIBARANI
PER/35/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
1400000000527
KLINIK PANDU
ANTONIUS
PER/36/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
1500000000237
62164746
HERDIANA GULTOM
PER/19/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
10
1400000000544
KLINIK PUTRI
6474965
DR.AMRAN
SITUMORANG
PER/37/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
11
1400000000534
KLINIK PUTRI
76137512
PER/38/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
12
1500000000236
KLINIK RIDHO
64530224
PER/18/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
13
1400000000050
60004795
ANDRE CHRISTIAN
PARSAORAN
SIMATUPANG
PER/39/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
14
1400000000050
60004795
ANDRE CHRISTIAN
PARSAORAN
SIMATUPANG
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
15
1500000000103
6574736
DR.IRENE HARTONO
PER/15/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
16
1500000000182
64731970
DR.JUNETA ZEBUA
PER/17/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
28 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1500000001813
PT.PRIMA MEDICA
NUSANTARA RS
BALIMBINGAN
JL.KOMPLEK RS BALIMBINGAN
KECAMATAN TANAH JAWA
21151
70829112
RS BALIMBINGAN
PER/ 25/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
18
1500000001814
PT.PRIMA MEDICA
NUSANTARA RS LARAS
21151
081260963
170
RS LARAS
PER/ 24 /072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
19
1500000001815
PT.PRIMA MEDICA
NUSANTARA RS PABATU
RS PABATU
PER/23 /072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
20
1400000000535
RSUD PERDAGANGAN
70324734
RSUD PERDAGANGAN
PER/29/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
21
1400000000676
RSUD PORSEA
61245547
PER/30/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
22
1400000000350
331170
RSUD TUAN
RONDAHAIM
PER/31/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
23
1400000000289
434171
PER/28/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
24
1400000000289
434171
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
25
1400000000545
62054053
RSUD PARAPAT
PER/32/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
26
1400000000343
21043
PER/33/TC/0120
16
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
27
1500000000589
22520
PER/22/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
29 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000608
BPS SARTIKA
081264339
055
MURSYID DALIMUNTE
PER/18/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000608
BPS SARTIKA
081264339
055
MURSYID DALIMUNTE
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000057
61311291
HAMZAH
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000057
61311291
HAMZAH
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000109
KLINIK AMANAH
7352111
DR. NURHIMSYAH
JUNEDI NASUTION
PER/29/122015
RS.TRAUMA
CENTRE
01/12/2016
29/12/2016
1400000000109
KLINIK AMANAH
7352111
DR. NURHIMSYAH
JUNEDI NASUTION
PER/25/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000109
KLINIK AMANAH
7352111
DR. NURHIMSYAH
JUNEDI NASUTION
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000606
KLINIK AULIA
085297350
468
RITA ADELINA
PER/16/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000606
KLINIK AULIA
085297350
468
RITA ADELINA
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1400000000609
082368310
000
ZULKARNAEN
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1400000000609
082368310
000
ZULKARNAEN
PER/17/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
12
1400000000607
081264339
055
MURSYID DALIMUNTE
PER/19/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
30 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
JL. BEDAGAI NO. 129 KOTAPINANG
KECAMATAN KOTA PINANG KABUPATEN
LABUHAN BATU SELATAN
JL. PERINTIS NO. 18 SIMPANG KAWAT
DUSUN I KELURAHAN HESSA
PERLOMPONGAN KECAMATAN AIR BATU
KABUPATEN ASAHAN
JL. PERINTIS NO. 18 SIMPANG KAWAT
DUSUN I KELURAHAN HESSA
PERLOMPONGAN KECAMATAN AIR BATU
KABUPATEN ASAHAN
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
081264339
055
MURSYID DALIMUNTE
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
081262861
45
DR PATAR MT
PANJAITAN
PER/30/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
081262861
45
DR PATAR MT
PANJAITAN
PER/21/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
620213
HARUN
PER/24/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
085261585
929
DRG ZANIYAR
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000714
085261585
929
DRG ZANIYAR
PER/30/12/2015
RS.TRAUMA
CENTRE
01/12/2016
31/12/2016
19
1400000000714
085261585
929
DRG ZANIYAR
PER/20/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
20
1400000000727
081262861
45
DR PATAR MT
PANJAITAN
PER/30/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21
1400000000727
081262861
45
DR PATAR MT
PANJAITAN
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1400000000718
KLINIK RAKYAT
081262861
45
DR PATAR MT
PANJAITAN
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23
1400000000718
KLINIK RAKYAT
081262861
45
DR PATAR MT
PANJAITAN
PER/22/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
1500000000677
KLINIK SAUDARA
082272368
299
KLINIK SAUDARA
PER/05/042015
RS.TRAUMA
CENTRE
22/04/2015
31/12/2015
13
1400000000607
14
1400000000728
KLINIK ESTOMIHI
15
1400000000728
KLINIK ESTOMIHI
16
1400000000203
KLINIK HARUN
17
1400000000714
18
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
31 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1500000000129
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1500000000129
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
27
1500000000662
PUSKESMAS INDRAPURA
081376616
429
PUSKESMAS INDRAPURA
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28
1500000000662
PUSKESMAS INDRAPURA
081376616
429
PUSKESMAS INDRAPURA
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
29
1500000000663
081361449
866
PUSKESMAS KEDAI
SIANAM
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
30
1500000000663
081361449
866
PUSKESMAS KEDAI
SIANAM
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
31
1500000000665
PUSKESMAS LABUHAN
RUKU
081362061
445
PUSKESMAS LABUHAN
RUKU
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
32
1500000000665
PUSKESMAS LABUHAN
RUKU
081362061
445
PUSKESMAS LABUHAN
RUKU
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
33
1500000000675
PUSKESMAS LALANG
PUSKESMAS LALANG
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
34
1500000000675
PUSKESMAS LALANG
PUSKESMAS LALANG
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
35
1500000000676
PUSKESMAS LAUTADOR
PUSKESMAS LAUTADOR
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
36
1500000000676
PUSKESMAS LAUTADOR
PUSKESMAS LAUTADOR
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
32 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
37
1500000000666
PUSKESMAS LIMA
PULUH
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
38
1500000000666
PUSKESMAS LIMA
PULUH
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
39
1500000000667
PUSKESMAS PAGURAWAN
PUSKESMAS
PAGURAWAN
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
40
1500000000667
PUSKESMAS PAGURAWAN
PUSKESMAS
PAGURAWAN
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
41
1500000000668
PUSKESMAS PEMATANG
PANJANG
081264704
44
PUSKESMAS PEMATANG
PANJANG
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
42
1500000000668
PUSKESMAS PEMATANG
PANJANG
081264704
44
PUSKESMAS PEMATANG
PANJANG
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
43
1500000000669
PUSKESMAS PETATAL
085275999
784
PUSKESMAS PETATAL
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
44
1500000000669
PUSKESMAS PETATAL
085275999
784
PUSKESMAS PETATAL
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
45
1500000000670
082360571
537
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
46
1500000000670
082360571
537
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
47
1500000000671
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
48
1500000000671
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
33 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
49
1500000000672
PUSKESMAS SIMPANG
DOLOK
081361063
456
PUSKESMAS SIMPANG
DOLOK
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
50
1500000000672
PUSKESMAS SIMPANG
DOLOK
081361063
456
PUSKESMAS SIMPANG
DOLOK
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
51
1500000000673
PUSKESMAS TANJUNG
TIRAM
081264222
800
PUSKESMAS TANJUNG
TIRAM
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
52
1500000000673
PUSKESMAS TANJUNG
TIRAM
081264222
800
PUSKESMAS TANJUNG
TIRAM
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
53
1500000000674
081361006
865
PUSKESMAS UJUNG
KUBU
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
54
1500000000674
081361006
865
PUSKESMAS UJUNG
KUBU
PER/04/042015
RS.TRAUMA
CENTRE
16/04/2015
31/12/2015
55
1400000000294
RS SETIO HUSODO
44999
MARDI
PER/30/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
56
1400000000294
RS SETIO HUSODO
44999
MARDI
PER/26/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
57
1500000001895
RSU AVICENNA
7672018
TOSIP TANJUNG
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
58
1500000001895
RSU AVICENNA
7672018
TOSIP TANJUNG
PER/07/082015
RS.TRAUMA
CENTRE
03/08/2015
31/12/2015
59
1500000001235
081360103
239
DR M LATIF
SITUMORANG
PER/30/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
60
1500000001235
081360103
239
DR M LATIF
SITUMORANG
PER/06/062015
RS.TRAUMA
CENTRE
04/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
34 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
61
1400000000468
42532
PER/27/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
62
1400000000468
42532
PER/30/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
63
1500000000541
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
64
1500000000541
PER/03/042015
RS.TRAUMA
CENTRE
16/01/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000532
BALAI PENGOBATAN
INSANI
1500000000259
DR ADE KURNIAWATHY
1500000000179
KLINIK ANANDA
1500000000185
1400000000584
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
RIANI HARNAS
NASUTION
PER/39/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
DR ADE KURNIAWATHY
PER/31/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
LAMSERIA NABABAN
PER/28/122014
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
KLINIK DAFFA
DR ELNI RUBIANTI
DAULAY
PER/21/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
HJ NURSYAM
PER/13/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
60280900
361450301
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
35 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1400000000585
KLINIK MEDICA
1500000000392
KLINIK RIZKY
1500000000316
1500000000221
10
1400000000579
11
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
DR.HJ.ZUNAIDAH
HASANAH M.KES
PER/18/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
DR MELVA ARWITA
LUBIS
PER/35/032015
RS.TRAUMA
CENTRE
01/03/2015
31/03/2015
63595343
DR DIAN ASPASIA
LIMBONG
PER/34/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
59236760
ELISA LIE
PER/29/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
61652465
DR H.LIGAM MA'ARUF
LUBIS
PER/14/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000581
JL OSWALD SIAHAAN NO 36
DR MARULI TUA
SILALAHI
PER/16/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
12
1400000000583
JL R SUPRAPTO NO 70 SIBOLGA
DR RIKKY N HARAHAP
PER/11/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
13
1500000000643
PRAKTEK DOKTER
SEMPAKATA KABAN
DR SEMPAKATA KABAN
PER/43/022015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
14
1500000000644
PER/42/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
15
1400000000580
DR SRI PRIHATIN K N
HARAHAP
PER/17/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
16
1400000000578
DR SRI WAHYUNI
PER/15/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
17
1500000000393
PRAKTEK DOKTER
SYAMSIDAR
DR SYAMSIDAR
PER/36/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
MA11222I
396746406
62646523
6455987
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
36 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
18
1500000000689
DR YUDIKA KRISTIANA
PER/40/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
19
1500000000178
PRAKTEK DR ASRIAL
DR ASRIAL
PER/27/022015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
20
1500000000177
PRAKTEK DR MEINI
BASYARIAH
DR MEINI BASYARIAH
PER/25/012015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
21
1400000000688
DR HOTMAULI
HUTAGALUNG MKES
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1400000000690
PUSKESMAS PAROMBUNAN
SAHAT D HUTAJULU
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
23
1400000000689
PUSKESMAS PELABUHAN
SAMBAS
DR IVONNA HASFIKA
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
1400000000686
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
25
1400000000687
PUSKESMAS SAMBAS
DR JULIATI SISKA
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
1400000000186
RS METTA MEDIKA
25007
PT METTA MEDIKA
PER/12/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
27
1500000000746
RSU BETHESDA
323316
DR YORIEN SETIA
ALFARIANTI LASE
PER/41/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
28
1500000000477
20279
DR H SAFII
SIREGAR,SPOG
PER/37/032015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
29
1500000000690
JL KIHAJAR DEWANTARA
421060
DR.MUSBAR
PER/38/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
37 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
31/12/2015
PER/19/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PEMDA
PER/22/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PEMERINTAH
PER/26/022015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
BAGINDA HARAHAP
PER/32/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
RUMKITBAN 01.08.02
SIBOLGA
JL ANGGREK NO 6 SIBOLGA
RUMKITBAN
PER/20/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
31
1400000000576
RSUD PANYABUNGAN
20181
32
1400000000344
RSUD SIBUHUAN
421678
33
1500000000176
34
1500000000260
35
1400000000586
KODE PROVIDER
AKHIR IKS
01/01/2015
RSUD PANDAN
NO
AWAL IKS
RS.TRAUMA
CENTRE
1400000000683
TIPE IKS
PER/24/122014
30
KANTOR CABANG
PIMPINAN
362180265
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001892
BALAI PENGOBATAN
HOMBING
085260446
061
DR. JANNES E.
SIHOMBING
PER/26/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
1500000001892
BALAI PENGOBATAN
HOMBING
085260446
061
DR. JANNES E.
SIHOMBING
PER/36/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
1400000000619
7942321
DR. ARSYAD
PER/33/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
38 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1400000000619
1400000000033
1400000000033
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
DR. ARSYAD
PER/20/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
TAN ERFI
PER/14/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
TAN ERFI
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000031
BPS MORAWA
7942361
TAN ERFI
PER/07/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000031
BPS MORAWA
7942361
TAN ERFI
PER/16/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
1400000000412
23443444
PER/19/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
10
1400000000412
23443444
PER/18/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
11
7-1240382124
KLINIK ABIZA
085359461
777
SAMSINAR
PER/29/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
12
1400000000405
441543
PER/18/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
13
1400000000405
441543
PER/17/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
14
1400000000037
KLINIK HAMIDAH
7945983
DIAN SARI
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
15
1400000000037
KLINIK HAMIDAH
7945983
DIAN SARI
PER/13/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
MA11222I
7942321
20995
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
39 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1400000000404
80019975
PER/20/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
17
1400000000404
80019975
PER/19/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
18
1500000001880
20351
7380666
PER/24/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
19
1500000001880
20351
7380666
PER/35/072015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
20
1500000000070
085275246
273
DR. MUHAMMAD
ARSHAD
PER/23/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
21
1500000000070
085275246
273
DR. MUHAMMAD
ARSHAD
PER/27/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
22
1500000000070
085275246
273
DR. MUHAMMAD
ARSHAD
PER/09/012015
RS.TRAUMA
CENTRE
01/01/2015
30/06/2015
23
1400000000590
PER/21/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
24
1400000000590
PER/28/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
25
1500000001879
20351
7952511
MARHEN, AMK
PER/25/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
26
1500000001879
20351
7952511
MARHEN, AMK
PER/34/072015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
27
1500000000069
081265238
15
PER/22/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
40 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
28
1500000000069
081265238
15
PER/08/02015
RS.TRAUMA
CENTRE
01/01/2015
30/06/2015
29
1500000000069
081265238
15
PER/29/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
30
7-1242107043
KLINIK PUJA
20585
PER/30/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
31
7-1239985383
KLINIK RAIHAN
20228
081265410
449
PER/28/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
32
1400000000032
7945676
SALMIAH ZAKARIA
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
33
1400000000032
7945676
SALMIAH ZAKARIA
PER/15/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
34
1400000000706
082167926
514
PER/27/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
35
1400000000719
081397941
999
PER/27/01/2016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
36
1400000000721
PUSKESMAS BANDAR
DOLOK
081376670
815
PER/27/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
37
1400000000709
PUSKESMAS BANDAR
KHALIPAH
081362408
181
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
38
1400000000682
PUSKESMAS BANGUN
PURBA
085262706
056
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
39
1400000000707
081265406
00
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
41 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
40
1400000000681
PUSKESMAS BIRU-BIRU
081262175
005
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
41
1400000000693
081376077
435
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
42
1400000000698
081264320
15
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
43
1400000000684
PUSKESMAS GALANG
081265876
80
PER/27/01/2016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
44
1400000000703
PUSKESMAS GUNUNG
MERIAH
081397999
343
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
45
1400000000711
PUSKESMAS HAMPARAN
PERAK
082160351
011
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
46
1400000000722
PUSKESMAS KARANG
ANYER
081272118
888
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
47
1400000000720
PUSKESMAS KENANGAN
085358348
281
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
48
1400000000723
082164747
266
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
49
1400000000726
PUSKESMAS KUTALIMBARU
081361326
400
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
50
1400000000710
081269230
222
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
51
1400000000705
085276730
440
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
42 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
52
1400000000697
PUSKESMAS MULIOREJO
081375333
643
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
53
1400000000699
PUSKESMAS NAMORAMBE
081264262
444
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
54
1400000000704
081265884
10
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
55
1500000000029
082168463
332
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
56
1400000000700
081263587
546
PER/27/01/2016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
57
1400000000694
PUSKESMAS PATUMBAK
085275960
879
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
58
1500000000030
PUSKESMAS PEMATANG
JOHAR
082160580
199
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
59
1500000000031
PUSKESMAS PETUMBUKAN
081264151
51
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
60
1400000000724
081370221
459
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
61
1400000000702
081160754
20
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
62
1400000000680
PUSKESMAS SIBOLANGIT
081264202
97
PER/27/01/2016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
63
1400000000725
PUSKESMAS SUKARAYA
081265013
29
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
43 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
64
1400000000701
081375190
502
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
65
1400000000685
PUSKESMAS TANJUNG
MORAWA
081375253
099
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
66
1400000000708
081264209
777
PER/27/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
67
1400000000678
081265818
732
PER/27/01/2016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
68
1500000000205
RS BHAYANGKARA TK.III
TEBING TINGGI
POLRI RI
PER/14/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2017
69
1400000000030
RS GRAND MEDISTRA
7955114
DRS. JOHANNES S
PER/03/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
70
1400000000030
RS GRAND MEDISTRA
7955114
DRS. JOHANNES S
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
71
1500000001957
RS MORAWA UTAMA
20351
7945058
PER/40/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
72
1500000001957
RS MORAWA UTAMA
20351
7945058
PER/12/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
73
1400000000589
RS PATAR ASIH
7950449
NATANIEL P.
NAINGGOLAN, SH
PER/06/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
74
1400000000589
RS PATAR ASIH
7950449
NATANIEL P.
NAINGGOLAN, SH
PER/31/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
75
1500000001981
RS SRI PAMELA
24748
PER/37/092015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
44 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
24748
PER/11/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
20362
7944796
PTPN II (PERSERO)
PER/01/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
20362
7944796
PTPN II (PERSERO)
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
21476
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
RSU HERNA
21476
PER/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000622
7990056
DR. TONDY
PER/25/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
82
1400000000622
7990056
DR. TONDY
PER/07/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
83
1400000000587
77607489
PER/23/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
84
1400000000587
77607489
PER/05/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
85
1400000000620
7951339
DRS. WASHINGTON
PURBA
PER/04/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
86
1400000000620
7951339
DRS. WASHINGTON
PURBA
PER/32/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
87
1500000000099
7030802
DRS. JOHANNES S
PER/26/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
76
1500000001981
RS SRI PAMELA
77
1400000000038
78
1400000000038
79
1400000000035
RSU HERNA
80
1400000000035
81
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
45 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
88
1500000000099
7030802
DRS. JOHANNES S
PER/10/012015
RS.TRAUMA
CENTRE
01/01/2015
30/06/2015
89
1500000000099
7030802
DRS. JOHANNES S
PER/08/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
90
1500000000248
7952068
PER/12/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
91
1500000000248
7952068
PER/09/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
92
1500000000204
PEMKAB SERDANG
BEDAGAI
PER/13/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
93
1500000000204
PEMKAB SERDANG
BEDAGAI
PER/10/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000054
BALAI PENGOBATAN
DELIMA
NURDELIMA SIHOMBING
PER/24/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000054
BALAI PENGOBATAN
DELIMA
NURDELIMA SIHOMBING
PER/08/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000053
KLINIK AZIZI
DR.ANITAWATI
PER/29/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
46 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000053
KLINIK AZIZI
DR.ANITAWATI
PER/05/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001219
DISIPLIN ROSALINA G
PER/08/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000001219
DISIPLIN ROSALINA G
PER/09/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000331
DR.YUDA PRAYOGI
PER/04/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000331
DR.YUDA PRAYOGI
PER/25/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000331
DR.YUDA PRAYOGI
PER/25/122014
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
10
1500000000231
KLINIK DANDY
20241
66516974
PER/26/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
11
1500000000231
KLINIK DANDY
20241
66516974
PER/01/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
12
1500000000250
TAKBIR SIREGAR
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
13
1500000000250
TAKBIR SIREGAR
PER/11/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
14
7-1135974186
TAKBIR SIREGAR
PER/11/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
15
1500000000251
TAKBIR SIREGAR
PER/10/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
20241
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
47 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1500000000251
TAKBIR SIREGAR
PER/03/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
17
1500000000052
TEGUH SUHARTO
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
18
1500000000052
TEGUH SUHARTO
PER/06/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
19
1500000000051
TEGUH SUHARTO,SE
PER/22/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
20
1500000000051
TEGUH SUHARTO,SE
PER/07/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21
1500000000459
20241
96333303
NURHAYATI PURBA
PER/05/032015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
22
1500000000459
20241
96333303
NURHAYATI PURBA
PER/02/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23
7-1919381394
20245
WENDY
PER/02/022016
RS.TRAUMA
CENTRE
05/02/2016
31/12/2016
24
7-1919381394
20245
WENDY
PER/02/022016
RS.TRAUMA
CENTRE
04/02/2016
31/01/2017
25
7-1918653373
20241
DR JOHNY HENDRIK
PER/01/022016
RS.TRAUMA
CENTRE
05/02/2016
31/12/2016
26
7-1918653373
20241
DR JOHNY HENDRIK
PER/01/022016
RS.TRAUMA
CENTRE
04/02/2016
31/01/2017
27
1400000000332
DR.KURNIAWAN
PER/21/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
48 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
28
1400000000332
DR.KURNIAWAN
PER/12/122014
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
29
1400000000332
DR.KURNIAWAN
PER/03/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
30
1500000000289
PUSKESMAS BELAWAN
JL MEDAN BELAWAN
PER/01/022015
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
31
1500000000287
PUSKESMAS BINJAI
PER/01/022015.0
3
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
32
1500000000288
PUSKESMAS BROMO
JL BROMO
PER/01/022015.0
2
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
33
1500000000286
PUSKESMAS DENAI
JL DENAI MEDAN
PER/01/022015.0
4
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
34
1500000000311
DR.SURYA SYAHPUTRA
PULUNGAN
PER/01/022015.1
1
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
35
1500000000285
PUSKESMAS GLUGUR
DARAT
JL PENDIDIKAN MEDAN
PER/01/022015.0
5
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
36
1500000000283
JL KL YOS SUDARSO
6942329
PER/01/022015.0
7
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
37
1500000000284
PUSKESMAS MANDALA
7351781
PER/01/022015.0
6
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
38
1500000000312
PUSKESMAS MARTUBUNG
JL.MARTUBUNG
4520331
DR,NURAISYAH
HASIBUAN
PER/01/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2020
39
1500000000304
4520331
DR.LININIATY DAELY
PER/01/022015.1
8
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
MA11222I
4520331
4520331
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
49 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
4520331
DR.NURLELIN
PER/01/022015.1
9
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
6856738
PER/01/022015.0
8
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
PUSKESMAS PB SERING
4520331
DR.REFRINI
PER/01/022015.1
4
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
1500000000281
PUSKESMAS PEKAN
LABUHAN
6856738
PER/01/022015.0
9
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
44
1500000000306
4520331
NURAISYAH HASIBUAN
PER/01/022015.1
6
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
45
1500000000305
JL.KEMIRI MEDAN
4520331
PER/01/022015.1
7
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
46
1500000000310
4520331
DR.SYARIFAH HANUM
PER/01/022015.1
2
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
47
1500000000307
4520331
ERNA SARI
PER/01/022015.1
5
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
48
1500000000309
4520331
DR.ERNA SARI
PER/01/022015.1
3
RS.TRAUMA
CENTRE
24/02/2015
23/02/2020
49
1400000000336
RS MARTHA FRISKA
RASIN BBA,MHA
PER/14/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
50
1400000000336
RS MARTHA FRISKA
RASIN BBA,MHA
PER/19/122014
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
51
1400000000336
RS MARTHA FRISKA
RASIN BBA,MHA
PER/19/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
40
1500000000303
41
1500000000282
PUSKESMAS MEDAN
LABUHAN
42
1500000000308
43
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
50 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
52
1400000000455
PER/15/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
53
1400000000455
PER/27/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
54
1400000000335
DR.IMELDA LIANA
RITONGA
PER/28/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
55
1400000000335
DR.IMELDA LIANA
RITONGA
PER/13/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
56
1400000000334
6941927
PT.PELABUHAN
INDONESIA
PER/12/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
57
1400000000334
6941927
PT.PELABUHAN
INDONESIA
PER/20/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
58
1500000000452
PER/07/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000067
BPS SARANA
1500000000922
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
DR KIKIE INDRIATY
TIPE IKS
AWAL IKS
AKHIR IKS
PER/01/012016
RS.TRAUMA
CENTRE
27/01/2016
31/12/2016
PER/04/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
51 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000210
DR BUDI JEFRI
PER/08/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1400000000209
DRS WASHINGTON
PER/017/082015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2016
1500000001924
20351
DR ELVII SUSANTI
SITEPU
PER/019/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
7-1958871584
20811
H BUDIANTO WAHYU
WARDOYO
PER/03/022016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
1500000000430
DR TUAHMAN
PER/02/032015
RS.TRAUMA
CENTRE
24/03/2015
23/03/2016
7-1958581253
EMA PURNAMA
PER/02/022016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
1500000000213
RS BANGKATAN PTPN II
75080063
PTPN II
PER/01/022015
RS.TRAUMA
CENTRE
18/02/2015
31/01/2016
10
1500000001203
RSIA SYLVANI
JL PERINTIS KEMERDEKAAN NO 21 LK V
KEL PAHLAWAN
80045925
DR SUGIANTO
PER/06/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
1500000001944
20351
65570210
SARMA HARO
PER/015/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
12
1500000001820
20351
8457573
SARMA HARO
PER/015/072015
FFS
01/07/2015
30/06/2016
13
1500000000429
RSU KELIAT
PRATEN NATALIA BR
KELIAT
PER/03/032015
RS.TRAUMA
CENTRE
25/03/2015
24/03/2016
14
1500000001925
PER/018/082015
RS.TRAUMA
CENTRE
03/08/2015
31/12/2016
MA11222I
370139966
396880292
20761
20111
8451638
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
52 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
AWAL IKS
AKHIR IKS
PER/40/092015
RS.TRAUMA
CENTRE
08/12/2015
31/12/2016
92544
PER/31/082015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
25552
92544
PER/32/082015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
25552
481291
PER/34/082015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
081363474
133
DR FERI MULYANI
PER/05/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
081363474
133
DR FERI MULYANI
PER/44/122015
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
1500000001984
KLINIK FANISA
25511
93205
DR YULFI ANETA
PER/39/092015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2016
1500000001970
KLINIK FITRIA
25161
775322
PER/37/092015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2016
1500000001871
25112
DR MARTHA EDDYWATI
PER/26/072015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000000954
JL H AGUS SALIM NO 19
NURMIDALMI, SE
PER/15/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
11
1500000001941
CV ARSY HENDRAMA
PER/33/082015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
12
1500000000813
JL PALEMBANG NO 20 GAUNG
PER/14/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
7-885661125
RS SEMEN PADANG
25161
1500000001953
KLINIK AISYIYAH II
KAMPUNG PERAK
25511
1500000001955
1500000001939
KLINIK AMANAH
1400000000040
1400000000040
MA11222I
YAYASAN RS SEMEN
PADANG
TIPE IKS
811150
25111
SM0480
Halaman :
Tanggal Cetak :
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53 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
13
1500000001025
KLINIK SIMPANG
ANDURING
14
1500000001954
RS AISYIYAH PARIAMAN
15
1500000000635
RS BHAYANGKARA
PADANG
JL JATI NO 1 PADANG
16
1500000000767
RS KHUSUS BEDAH
KARTIKA DOCTA
17
1500000001054
RS SELAGURI
JL JEND A. YANI NO 26
18
7-797923945
RS SITI RAHMAH
19
1400000000039
RS TENTARA
REKSODIWIRYO
20
1400000000039
RS TENTARA
REKSODIWIRYO
21
7-919921504
22
1500000000955
23
1500000001940
24
1500000001956
MA11222I
KODE
POS
25511
IKS
TELEPON
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PROF DR H ZULKARNAIN
ARSYAD, SPPD-KP
PER/17/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PD AISYIYAH KOTA
PARIAMAN
PER/30/082015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
POLDA SUMBAR
PER/11/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
H. MUSTAFA KAMAL
PER/12/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
DR HJ HAFLEZIANI
M.KES
PER/18/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/41/092015
RS.TRAUMA
CENTRE
04/12/2015
31/12/2016
31003
DATASEMEN
KESEHATAN
PER/45/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
31003
DATASEMEN
KESEHATAN
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
YAYASAN RS ISLAM
SUMATERA BARAT
PER/43/122015
RS.TRAUMA
CENTRE
18/12/2015
31/12/2016
PEMDA PESISIR
SELATAN
PER/13/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
PEMERINTAH KOTA
PADANG
PER/35/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
PER/36/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
92544
4481278
25173
25142
214282151
8
25231
PIMPINAN
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
54 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
9111891428
30/04/2016
PER/28/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2016
PER/03/012016
RS.TRAUMA
CENTRE
01/04/2016
31/12/2016
31938
PER/09/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
63385109
MAWARDI
PER/10/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
JL PROF M YAMIN SH NO 5
26
1500000001920
27
1500000000507
31938
28
1500000000507
29
1500000000534
NO
KODE PROVIDER
AKHIR IKS
01/05/2015
RSUD PARIAMAN
AWAL IKS
RS.TRAUMA
CENTRE
1500000000914
KANTOR CABANG
TIPE IKS
PER/16/052015
25
25111
PIMPINAN
PEMPROV SUMBAR
32371
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001070
KLINIK ALIF
EVA YULIA
PER/010/052015
FFS
01/06/2015
31/12/2016
1500000001058
KLINIK AQILAH
DR HJ MARISSA
PER/06/052015
FFS
01/06/2015
31/12/2016
1500000001059
DR H AGUNG MULIA
MARS
PER/09/052015
FFS
01/06/2015
31/12/2016
1500000001104
HERMALIS
PER/011/052015
FFS
01/06/2015
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
55 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001949
1500000001161
PRAKTEK DR MARNIYANTI
1500000001050
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
AWAL IKS
AKHIR IKS
PT AMP PLANTATION
PER/013/092015
FFS
01/09/2015
31/08/2016
DR MARNIYANTI
PER/08/052015
FFS
01/06/2015
31/12/2016
PRAKTEK DR SONYA
THEMIARTO
DR SONYA THEMIARTO
PER/05/052015
FFS
01/06/2015
31/05/2016
1400000000280
PRAKTEK DR SYAHRIL S
DR SYAHRIL S
PER/015/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000223
JL PEMUDA NO 14 PAYAKUMBUH
92222
YARSI SUMATERA
BARAT
PER/013/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1400000000239
7464015
PER/016/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1400000000239
7464015
PER/014/072014
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
12
1400000000063
RSUD DR ACHMAD
MOCHTAR BUKITTINGGI
21720
PEMERINTAH PROVINSI
SUMATERA BARAT
PER/014/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1500000000076
82046
PEMDA PADANG
PANJANG
PER/001/012015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
14
1500000000817
76017
PEMDA AGAM
PER/003/042015
FFS
01/05/2015
30/04/2017
15
1500000001169
93632
DASWING SPD
PER/07/052015
FFS
01/06/2015
31/12/2016
KANTOR CABANG
MA11222I
26151
TIPE IKS
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
56 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000548
ZULFAKHRI,S.SOS
PER/03/032015
FFS
02/03/2015
31/12/2015
1500000000548
ZULFAKHRI,S.SOS
PER/18/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
1400000000099
BLUD-RSUD SAWAHLUNTO
JL KARTINI NO 18
74066837
PER/14/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1400000000099
BLUD-RSUD SAWAHLUNTO
JL KARTINI NO 18
74066837
PER/07/122015
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
1500000000749
KLINIK ALTHAF
JL M YAMIN NO 83
PER/14/122015
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
1500000000749
KLINIK ALTHAF
JL M YAMIN NO 83
PER/12/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000722
KLINIK ARBA
YUSNIMAR SST
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000722
KLINIK ARBA
YUSNIMAR SST
PER/12/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
1500000000761
KLINIK KURNIA
EVAMAIROZA,SE,M.KES
PER/15/122015
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
10
1500000000761
KLINIK KURNIA
EVAMAIROZA,SE,M.KES
PER/13/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
11
1500000000948
NURJINIS
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
12
1500000000948
NURJINIS
PER/13/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
57 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000895
PUSKESMAS ALAHAN
PANJANG
PER/11/052015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
14
1500000000895
PUSKESMAS ALAHAN
PANJANG
PER/16/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
15
1500000000748
PUSKESMAS TALANG
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
16
1500000000547
RSUD AROSUKA
KABUPATEN SOLOK
DR.I.NYOMAN ARDANA
PUTRA
PER/10/122015
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
17
1500000000547
RSUD AROSUKA
KABUPATEN SOLOK
DR.I.NYOMAN ARDANA
PUTRA
PER/03/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
18
1500000000464
RSUD SIJUNJUNG
20056
PER/08/122015
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
19
1500000000464
RSUD SIJUNJUNG
20056
PER/01/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
20
1400000000017
RSUD SOLOK
20826
RSUD SOLOK
PER/09/122015
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
21
1400000000017
RSUD SOLOK
20826
RSUD SOLOK
PER/05/032015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
22
1500000000466
40347
PER/11/122015
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
23
1500000000466
40347
PER/02/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
58 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
7-129782961
7-126189943
FASKES KOKOLATE
1500000001877
KLINIK FELLITA
28111
1500000001877
KLINIK FELLITA
28111
1500000001988
KLINIK FIDYA
1500000001988
IKS
TELEPON
PIMPINAN
NO IKS
10150
TIPE IKS
AWAL IKS
AKHIR IKS
SUHESI MAHENDRA
112233
28/09/2015
31/12/2015
NORA
11333
15/09/2015
16/12/2015
68401901
PER/35/072015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
68401901
PER/35/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
72026643
PER/41/102015
RS.TRAUMA
CENTRE
05/10/2015
31/12/2015
KLINIK FIDYA
72026643
PER/41/102015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000301
68015266
KHAIRUL MAWARDI
PER/12/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1500000001878
28411
76892989
FEBRIAN
CHASRA,SE.S.FILL
PER/37/072015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001878
28411
76892989
FEBRIAN
CHASRA,SE.S.FILL
PER/37/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
10
1500000000240
085364646
865
DR M FAJAR HANAFI
PER/07/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
11
1500000001770
28262
05617614
ARMAINI, SH
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001770
28262
05617614
ARMAINI, SH
PER/31/062015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
KODE
POS
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
59 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
7-492772759
KLINIK PRATAMA
CENDANA HUSADA
28151
HJ. ELLIYANNORA
PER/46/112015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
14
7-492772759
KLINIK PRATAMA
CENDANA HUSADA
28151
HJ. ELLIYANNORA
PER/46/112015
RS.TRAUMA
CENTRE
27/11/2015
31/12/2015
15
7-522122673
28383
HERMALINDA
PER/48/112015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
16
7-522122673
28383
HERMALINDA
PER/48/112015
RS.TRAUMA
CENTRE
27/11/2015
31/12/2015
17
1400000000029
KLINIK RAUDAH
4881091
DR.GUSRIANTI
PER/06/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
18
1500000000243
RS AMALIA MEDIKA
95348
H UJANG MALIK SE
PER/09/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
19
1200000000002
RS AWAL BROS
47333
82/IKS/0612
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
20
1400000000036
RS EFARINA
494500
PT EFARINA
PER/10/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
21
1200000000001
RS PROF DR TABRANI
JL SUDIRMAN NO 410
35464
PROF. DR TRABRANI
PER/18/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
22
1400000000100
RS SYAFIRA
3061000
DR IRANA OKTAVIA
13033896716
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
23
1400000000100
RS SYAFIRA
3061000
DR IRANA OKTAVIA
PER/16/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
24
1500000000241
20012
HJ.ULFAH HANUM
PER/08/032015
RS.TRAUMA
CENTRE
28/02/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
60 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
20012
HJ.ULFAH HANUM
PER/08/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
076123954
PER/49/122015
RS.TRAUMA
CENTRE
07/12/2015
31/12/2016
21718
DEWI KHUSNIATY
PER/21/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
28122
0761 24242
PER/45/112015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28122
0761 24242
PER/45/112015
RS.TRAUMA
CENTRE
27/11/2015
31/12/2015
848100
PT. PEKANBARU
MEDIKAL SENTER
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
848100
PT. PEKANBARU
MEDIKAL SENTER
PER/27/062015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000141
JL KESEHATAN NO 1 PEKANBARU
22426
DR.YUDHI DORANDES
PER/02/022015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
33
1500000000141
JL KESEHATAN NO 1 PEKANBARU
22426
DR.YUDHI DORANDES
PER/02/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
34
7-131427341
SATYA LENCANA
JLN JOJO NO 2
KOKO
12121111
RS.TRAUMA
CENTRE
01/01/2015
02/10/2015
25
1500000000241
26
7-791544013
27
1500000001028
28
7-300282953
29
7-300282953
30
1500000001341
31
1500000001341
32
KANTOR CABANG
MA11222I
28115
10150
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
61 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000014
484427
DR ERIKA M KAMIL
PER/06/022015
RS.TRAUMA
CENTRE
24/02/2015
23/02/2016
1500000000461
KLINIK ANANDA
081270276
85
KLINIK ANANDA
PER/17/032015
RS.TRAUMA
CENTRE
26/03/2015
25/03/2016
1500000001213
KLINIK AZZAHRA
KLINIK AZZAHRA
PER/35/042015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2016
1500000001213
KLINIK AZZAHRA
KLINIK AZZAHRA
PER/35/042015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2016
1500000001213
KLINIK AZZAHRA
KLINIK AZZAHRA
PER/35/042015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2016
1500000000924
KLINIK ERNES
DR.ODRI ANGNES T
01/05 / ERNES
/2015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001281
PER/44/062015
RS.TRAUMA
CENTRE
11/06/2015
10/06/2016
1500000001280
PER/43/062015
RS.TRAUMA
CENTRE
11/06/2015
10/06/2016
1500000001282
PER/45/062015
RS.TRAUMA
CENTRE
11/06/2015
10/06/2016
10
1500000000439
KLINIK PARIWISATA
LAGOI
PER/13/032015
RS.TRAUMA
CENTRE
10/03/2015
09/03/2016
11
1500000001980
PER/52/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2016
12
1500000001979
PER/53/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
MA11222I
085265696
020
081277692
69
29112
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
62 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000001974
29113
PER/54/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2016
14
1500000001974
29113
PER/54/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2016
15
1500000000322
PER/09/032015
RS.TRAUMA
CENTRE
09/03/2015
08/03/2016
16
1500000000825
PUSKESMAS BATU 10
PUSKESMAS BATU 10
PER/40/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
17
1500000000321
PUSKESMAS KAMPUNG
BUGIS
PUSKESMAS KAMPUNG
BUGIS
PER/ 10 / 032015
RS.TRAUMA
CENTRE
09/03/2015
08/03/2016
18
1500000001526
PUSKESMAS KAWAL
PEMERINTAH KAB.
BINTAN
PER/46/062015
RS.TRAUMA
CENTRE
15/06/2015
14/06/2016
19
1500000001716
PUSKESMAS KIJANG
PUSKESMAS KIJANG
61118
PUSKESMAS KIJANG
PER/48/062015
RS.TRAUMA
CENTRE
29/06/2015
28/06/2016
20
1500000000923
JL CENDERAWASIH KM 8 TANJUNGPINANG
7003559
RIAMA SARAGI
PER/400/186/5.6.
11/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
21
1500000000638
PUSKESMAS MELAYU
KOTA PIRING
PER/34/042015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2016
22
1500000001969
PUSKESMAS NUMBING
29132
PUSKESMAS NUMBING
PER/56/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2016
23
1500000001969
PUSKESMAS NUMBING
29132
PUSKESMAS NUMBING
PER/56/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2016
24
1500000000823
PER/38/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
MA11222I
29132
26239
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
63 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PUSKESMAS
TANJUNGPINANG/PANCU
R
PER/39/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
085365206
193
PUSKESMAS TELUK
SASAH
PER/19/042015
RS.TRAUMA
CENTRE
07/04/2015
06/04/2016
081277692
69
PUSKESMAS TELUK
SEBONG
PER/12/032015
RS.TRAUMA
CENTRE
10/03/2015
09/03/2016
RSUD KABUPATEN
BINTAN
PER/37/042015
RS.TRAUMA
CENTRE
29/04/2015
28/04/2016
482795
PEMERINTAH PROPINSI
KEPRI
PER/11/032015
RS.TRAUMA
CENTRE
03/03/2015
02/03/2016
JL SUDIRMAN 795
313000
RSUD KOTA
TANJUNGPINANG
PER/18/032015
RS.TRAUMA
CENTRE
30/03/2015
29/03/2016
RSUD NATUNA
31128
RSUD NATUNA
PER/47/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2016
1400000000013
RSUP KEPRI
TANJUNGPINANG KM 8
PEMERINTAH PROVINSI
KEPULAUAN RIAU
PER/05/022015
RS.TRAUMA
CENTRE
07/02/2015
06/02/2016
1500000001890
JL. DI PANJAITAN KM 8 NO 12
PER/14/032015
RS.TRAUMA
CENTRE
25/03/2015
24/03/2016
25
1500000000824
PUSKESMAS
TANJUNGPINANG/PANCUR
26
1500000000502
27
1500000000437
28
1400000000093
29
1400000000061
30
1500000000462
RSUD KOTA
TANJUNGPINANG
31
1500000001609
32
33
KANTOR CABANG
MA11222I
7007758
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
64 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000048
BATAMINDO INDUSTRIAL
PARK KLINIK
29433
611907
BATAMINDO
INDUSTRIAL PARK
KLINIK
PER/59/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000048
BATAMINDO INDUSTRIAL
PARK KLINIK
29433
611907
BATAMINDO
INDUSTRIAL PARK
KLINIK
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000382
29466
761740
DR MELATI
PER/62/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000382
29466
761740
DR MELATI
PER/11/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000026
BP BUDI ROSARI
29458
BC GULIMAN
MANURUNG
PER/58/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000026
BP BUDI ROSARI
29458
BC GULIMAN
MANURUNG
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000595
29438
PT AUDY JAYA
PRATAMA
PER/47/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2015
7-764947233
29432
PT AUDY JAYA
PRATAMA
PER/45/122015
RS.TRAUMA
CENTRE
01/12/2015
31/12/2016
1400000000025
29464
8096104
YULIANA AMD.KEB SE
PER/04/012015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
10
1400000000025
29464
8096104
YULIANA AMD.KEB SE
PER/50/12015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1500000000587
BP HARAPAN KITA
SUKAJADI
29464
7372056
YULIANA AMD.KEB, SE
PER/51/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
12
1500000000587
BP HARAPAN KITA
SUKAJADI
29464
7372056
YULIANA AMD.KEB, SE
PER/18/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
MA11222I
077836147
5
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
65 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
7-769170004
29433
077880995
68
PT AUDY JAYA
PRATAMA
PER/46/122015
RS.TRAUMA
CENTRE
01/12/2015
31/12/2016
14
7-791402413
29431
077874972
76
PER/49/122015
RS.TRAUMA
CENTRE
18/12/2015
31/12/2016
15
1500000000348
29467
711569
EMMI KRISTIANI
SIREGAR
PER/64/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
16
1500000000348
29467
711569
EMMI KRISTIANI
SIREGAR
PER/17/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
17
1400000000644
KLINIK BATAMEDIKA
29437
64212392
DR KRISMADIES M.KKK
PER/48/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
18
1500000000822
KLINIK HUSADATAMA
29444
431457
DR.KRISMADIES, M.KKK
PER/22/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
19
1500000000822
KLINIK HUSADATAMA
29444
431457
DR.KRISMADIES, M.KKK
PER/57/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
20
1400000000072
KLINIK MEDIKA
29425
082389094
888
DR KRISMADIES, M.KKK
PER/08/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
21
1400000000072
KLINIK MEDIKA
29425
082389094
888
DR KRISMADIES, M.KKK
PER/53/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
22
1400000000466
29467
711448
PT NAYAKA ERA
HUSADA
PER/12/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
23
1400000000466
29467
711448
PT NAYAKA ERA
HUSADA
PER/64/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
24
1400000000074
29454
457857
DODDY SUDRAJAT
PER/60/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
66 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1400000000074
29454
457857
DODDY SUDRAJAT
PER/09/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
1400000000071
29433
371338
DR KRISMADIES, M.KKK
PER/52/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
27
1400000000071
29433
371338
DR KRISMADIES, M.KKK
PER/07/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
28
1500000000821
29458
61433634
DR.KRISMADIES,M.KKK
PER/56/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
29
1500000000821
29458
61433634
DR.KRISMADIES,M.KKK
PER/21/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
30
1500000000819
29464
38701249
DR KRISMADIES, M.KKK
PER/19/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
31
1500000000819
29464
38701249
DR KRISMADIES, M.KKK
PER/54/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
32
1400000000297
KLINIK TAMARA
29464
8097629
DR ANJARI WAHYU
WARDHANI
PER/10/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
33
1400000000297
KLINIK TAMARA
29464
8097629
DR ANJARI WAHYU
WARDHANI
PER/61/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
34
1500000000820
KLINIK XYSTERA
29439
7293995
DR KRISMADIES, M.KKK
PER/20/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
35
1500000000820
KLINIK XYSTERA
29439
7293995
DR KRISMADIES, M.KKK
PER/55/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
36
0900000000028
RS AWAL BROS
431777
DR WIDYA PUTRI
PER/01/012016
RS.TRAUMA
CENTRE
11/01/2016
31/03/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
67 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
431777
DR WIDYA PUTRI
PER/01/012015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
29432
077845404
4
SRI SOEDARSONO
PER/44/122015
RS.TRAUMA
CENTRE
01/12/2015
31/12/2016
29433
371003
PT CAMATHA SAHIDYA
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
RS CAMATHA SAHIDYA
29433
371003
PT CAMATHA SAHIDYA
PER/65/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1300000000017
RS HARAPAN BUNDA
29452
457333
YAYASAN HARAPAN
BUNDA
PER/03/012015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
1300000000017
RS HARAPAN BUNDA
29452
457333
YAYASAN HARAPAN
BUNDA
PER/66/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
37
0900000000028
RS AWAL BROS
38
7-768491263
RS BUDI KEMULIAAN
BATAM
39
0700000000015
RS CAMATHA SAHIDYA
40
0700000000015
41
42
KANTOR CABANG
NO
KODE
POS
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1400000000208
BALAI PENGOBATAN
MUTIARA KASIH
1500000000239
BP AMANAH
1500000000239
BP AMANAH
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
IR BURJU SIHOMBING
PER / 21 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
28882
PER/45/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28882
PER/04/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
68 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000024
28811
439026
DR RAHMI SALBI
PER/16/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
1400000000024
28811
439026
DR RAHMI SALBI
PER/47/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000024
28811
439026
DR RAHMI SALBI
PER/16/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
1500000000623
KLINIK AL UMMI
28811
34351
ANDI RONI
PER/17/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000623
KLINIK AL UMMI
28811
34351
ANDI RONI
PER/43/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000622
28813
34351
ANDI RONI
PER/18/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
10
1500000000622
28813
34351
ANDI RONI
PER/44/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1400000000518
28953
MUHAMMAD SYUKRI
PER/48/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
12
1500000000238
KLINIK SEHATI
28811
34584
DR. H. SUNARYO
PER/03/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
13
1500000000238
KLINIK SEHATI
28811
34584
DR. H. SUNARYO
PER/46/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
14
1500000001416
PER/28/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
15
1500000001407
PER/38/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
69 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1500000001391
PER/23/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
17
1500000001408
PER/37/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
18
1500000001405
PER/24/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
19
1500000001412
PER/32/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
20
1500000001417
PER/27/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
21
1500000000424
DINAS KESEHATAN
KOTA DUMAI
PER/13/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
22
1500000000426
DINAS KESEHATAN
KOTA DUMAI
PER/15/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
23
1500000000432
DINAS KESEHATAN
KOTA DUMAI
PER/11/03/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
24
1500000000423
DINAS KESEHATAN
KOTA DUMAI
PER/10/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
25
1500000000422
DINAS KESEHATAN
KOTA DUMAI
PER/08/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
26
1500000000419
DINAS KESEHATAN
KOTA DUMAI
PER/06/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
27
1500000000421
PKM JAYAMUKTI
DINAS KESEHATAN
KOTA DUMAI
PER/07/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
70 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
28
1500000000425
29
1500000001410
30
1500000001406
PKM PEDAMARAN
31
1500000001413
PKM PUJUD
32
1500000000420
33
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
AWAL IKS
AKHIR IKS
PER/14/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/34/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER/39/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER/31/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PKM PURNAMA
DINAS KESEHATAN
KOTA DUMAI
PER/09/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000001641
PKM RANTAU
KOPAR
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
34
1500000001418
PER/26/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
35
1500000001419
PER/25/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
36
1500000001414
PKM SEDINGINAN
JL KH ALIMUDDIN NO 03
PER/30/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
37
1500000001415
PER/29/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
38
1500000001411
PKM SINABOI
PER/33/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
39
1500000000433
PER/12/03/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
DINAS KESEHATAN
KOTA DUMAI
TIPE IKS
DINAS KESEHATAN
KOTA DUMAI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
71 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
40
1500000001409
41
1400000000492
RS CAHAYA
42
1400000000207
RSUD DR RM PRATOMO
43
1300000000020
44
1300000000020
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/35/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
66818300
PER/49/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21731
RSUD DR RM PRATOMO
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
RSUD DUMAI
JL TANJUNG JATI NO 4
38367
PEMKO DUMAI
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
RSUD DUMAI
JL TANJUNG JATI NO 4
38367
PEMKO DUMAI
PER/50/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28983
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-693615009
28382
DR RACHMAD
SURYAWAN
PER/16/112015
RS.TRAUMA
CENTRE
01/12/2015
31/12/2016
7-692702507
KLINIK DINDA
28384
DR RACHMAD
SURYAWAN
PER/17/112015
RS.TRAUMA
CENTRE
01/12/2015
31/12/2016
1500000000171
7642345
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000130
KLINIK MEDISSRA
71876761
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
ROHAIDAH
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
72 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000263
KLINIK MUIZZAH
PER/11/062015
RS.TRAUMA
CENTRE
01/08/2015
31/07/2016
1400000000262
KLINIK MUIZZAH 2
PER/12/062015
RS.TRAUMA
CENTRE
01/08/2015
31/07/2016
1500000000657
081268681
86
PER/08/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
7-1200888333
29211
00021717
CV INHIL SEHAT
BERSAMA
PER/18/122015
RS.TRAUMA
CENTRE
29/12/2015
31/12/2016
1500000001907
PUSKESAMS LIRIK
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
10
1500000001906
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
11
1500000001897
PUSKESMAS BATANG
PERANAP
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
12
1500000001913
PUSKESMAS KAMPUNG
BESAR KOTA
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
13
1500000001901
PUSKESMAS KILAN
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
14
1500000001914
PUSKESMAS KUALA
CENAKU
29335
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
15
1500000001910
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
16
1500000001902
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
73 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1500000001900
PUSKESMAS PANGKALAN
KASAI
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
18
1500000001911
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
19
1500000001898
PUSKESMAS PERANAP
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
20
1500000001904
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
21
1500000001905
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
22
1500000001903
PUSKESMAS SEBERIDA
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
23
1500000001908
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
24
1500000001899
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
25
1500000001912
PUSKESMAS SIPAYUNG
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
26
1500000001909
29312
DINAS KESEHATAN
PER/09/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
27
1500000000658
RS INDRAGIRI TEMBILAHAN
PT KENCANA INDRAGIRI
MEDIKA
PER/02/012015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
28
1400000000267
DR. IBRAHIM
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
7662247
23555
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
74 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
29
1500000000664
JL VETERAN NO 52 TEMBILAHAN
30
1500000001978
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
76822118
29511
TIPE IKS
AWAL IKS
AKHIR IKS
PEMKAB INHIL
PER/06/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PEMDA KUANSING
PER/14/102015
RS.TRAUMA
CENTRE
15/10/2015
31/12/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000092
92404
HARIANSYAH
PER/06/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000086
594469
NENNI TRIANA
PER/07/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000412
598085
PT NAYAKA ERA
HUSADA
PER/02/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000000413
560757
PT NAYAKA ERA
HUSADA
PER/03/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
7-1704752493
AFRIZAL TANJUNG
7-1704752493
RS.TRAUMA
CENTRE
02/02/2016
31/12/2016
1500000000411
71049091
RUSYDI
PER/01/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000000593
RSUD KECAMATAN
MANDAU
7038918
RSUD KECAMATAN
MANDAU
PER/04/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
28784
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
75 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
1400000000085
KANTOR CABANG
NO
NAMA PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
PIMPINAN
NO IKS
94902
PER/05/042015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/05/2015
AKHIR IKS
30/04/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
1500000001036
KLINIK ALKADRIAH
7-469185283
1500000000754
1500000000766
JL GARUDA SAKTI KM 2
1500000001032
1500000001027
7-329288012
28452
7-616675225
28291
PIMPINAN
NO IKS
081276480
467
MA11222I
IKS
TELEPON
TIPE IKS
AWAL IKS
AKHIR IKS
ROMMY ADRIANTO
PER/12/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
HJ ROSINA. SKM
PER/20/112015
RS.TRAUMA
CENTRE
19/11/2015
11/11/2016
082311116
191
MULYADI B
PER/08/052015
RS.TRAUMA
CENTRE
11/05/2015
10/05/2016
7875077
DR ADOLF BASTIAN
TAMBUSAI.M.PD
PER/07/052015
RS.TRAUMA
CENTRE
11/05/2015
10/05/2016
ZUSHENI GAYATRI
PER/14/052015
RS.TRAUMA
CENTRE
27/05/2015
26/05/2016
081365798
138
PER/11/052015
RS.TRAUMA
CENTRE
26/05/2015
25/05/2016
076170146
27
DR AMELIA ANGGREINI
MILALA
PER/16/112015
RS.TRAUMA
CENTRE
12/11/2015
09/11/2016
HJ ELLIYANNORA
PER/22/112015
RS.TRAUMA
CENTRE
27/11/2015
24/11/2016
28464
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
76 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
7-325123713
10
1500000000538
11
1500000000986
12
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
082288498
728
DR MERY SISCANOVA
PUTRI
PER/17/112015
RS.TRAUMA
CENTRE
11/11/2015
09/11/2016
7872833
DR DEFRI
PER/04/042015
RS.TRAUMA
CENTRE
15/04/2015
14/04/2016
586888
IR ARFAN AWALOEDDIN
MARS
PER/10/052015
RS.TRAUMA
CENTRE
13/05/2015
12/05/2016
1400000000152
7363329
PER/13/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
13
1500000000646
RS SURYA INSANI
7003404
PT.SURYA INSANI
PER/05/042015
RS.TRAUMA
CENTRE
22/04/2015
21/04/2016
14
1500000000770
081243533
006
DR ANDRI SETIAWAN
PER/09/052015
RS.TRAUMA
CENTRE
12/05/2015
11/05/2016
15
1400000000027
564666
SYAHRONI TUA
PER/03/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
KANTOR CABANG
NO
KODE PROVIDER
28125
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000475
495120
M. TABRI
PER/03/032015
RS.TRAUMA
CENTRE
27/03/2015
27/03/2016
1400000000011
7042991
MARTHEN TANDIRURA
PER/01/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
77 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001972
29412
322704
HJ GUSNAWATI
PER/38/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
7-1265428985
29428
077835829
23
RIRIS LIANI
PER/02/012016
RS.TRAUMA
CENTRE
05/01/2016
03/01/2017
1500000001252
325100
DR JUSRIZAL
PER/36/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001253
082391076
669
DR JUSRIZAL
PER/35 /052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001390
081931178
484
PER/37/062015
RS.TRAUMA
CENTRE
17/06/2015
16/06/2016
1400000000255
KLINIK VELY
9131737
PER/01/01/2016
RS.TRAUMA
CENTRE
05/01/2016
03/02/2017
1400000000132
392748
SYARIEF A. FAHMI, ST
PER/03/012016
RS.TRAUMA
CENTRE
05/01/2016
03/01/2017
10
1500000000494
PER/31/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
11
1500000001982
RS GRAHA HERMINE
PER/039/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
12
1000000000005
PER/32/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
13
1305070000021
KOTA BATAM
PER/34/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
KANTOR CABANG
MA11222I
29422
21060
29412
363318
364446
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
78 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000660
PER / 08 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000000523
PER / 02 /
032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000001212
PER / 14 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
1500000001008
PER / 13 /
052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000000851
PUSKESMAS MERSAM
PER / 11 /
052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000000852
PUSKESMAS MUARA
TEMBESI
PER / 12 /
052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000000631
PER / 09 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1500000000531
PUSKESMAS PAAL X
98555604
PER / 03 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
1500000000545
744901
PER / 05 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
10
1500000001211
PER / 16 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
11
1500000001243
PUSKESMAS SIMPANG
KAWAT
PER / 17 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
12
1500000000546
PUSKESMAS TAHTUL
YAMAN
PER / 06 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
MA11222I
74066247
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
79 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000543
PUSKESMAS TANJUNG
PINANG
10001415
PER / 04 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
14
1400000000559
RS BHAYANGKARA JAMBI
JL RADEN MATTAHER NO 03
23246
PER / 03 /
012016
RS.TRAUMA
CENTRE
20/01/2016
30/11/2016
15
0700000000017
RS DR BRATANATA
JL RD MATTAHER NO 33
20388
PER / 02 /
012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
16
1500000001224
RS RIMBO MEDIKA
PER / 15 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
17
1400000000560
PER / 01 /
012016
RS.TRAUMA
CENTRE
20/01/2016
30/11/2016
18
1400000000095
PERJ/07/042015
RS.TRAUMA
CENTRE
21/04/2015
30/03/2016
19
1400000000096
PER / 19 /
082015
RS.TRAUMA
CENTRE
21/04/2015
31/12/2015
20
1000000000004
PER / 18 /
072015
RS.TRAUMA
CENTRE
08/04/2015
31/12/2015
21
1400000000250
81258045
PER / 20 /
082015
RS.TRAUMA
CENTRE
09/06/2015
31/12/2015
22
1400000000094
61692
PERJ/001/012015
RS.TRAUMA
CENTRE
10/01/2015
31/12/2015
23
1500000000850
PER / 10 /
052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
KANTOR CABANG
MA11222I
RS DR BRATANATA
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
80 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/01/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
POLRES MERANGIN
PER/02/042015
RS.TRAUMA
CENTRE
09/04/2015
08/04/2017
PER/04/042015
RS.TRAUMA
CENTRE
24/04/2015
23/04/2016
M EFFENDI HARAHAP
PER/08/062015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000000958
MARLENA HARTATI
PER/05/052015
RS.TRAUMA
CENTRE
25/05/2015
26/05/2016
1500000001154
PER/07/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001149
PUSKEMAS MUKO-MUKO
BATHIN VII TC
JL KOMPLEK PERKANTORAN NO 02
TANJUNG AGUNG KEC MUKO-MUKO
BATHIN VII
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001153
PUSKEMAS RANTAU
KELOYANG
PER/05/062016
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001136
PUSKESMAS BABEKO TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000001148
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
1500000001150
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
12
1500000001140
PUSKESMAS KUAMANG
JAYA TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000315
1500000000520
KLINIK BHAYANGKARA
POLRES MERANGIN
1500000000634
1400000000052
MA11222I
21046
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
81 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000001139
PUSKESMAS KUAMANG
KUNING I TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
1500000001138
PUSKESMAS KUAMANG
KUNING X TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
15
1500000001152
PUSKESMAS LIMBUR
LUBUK MENGKUANG TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1500000001147
DINAS KESEHATAN
KABUPATEN BUNGO
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
17
1500000001137
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
18
1500000001146
PUSKESMAS PELAYANG TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
19
1500000001151
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
20
1500000001143
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
21
1500000001141
PUSKESMAS RANTAU
PANDAN TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
22
1500000001144
PUSKESMAS TANAH
SEPENGGAL LINTAS TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
23
1500000001145
PUSKESMAS TANAH
SEPENGGAL TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
24
1500000001142
PUSKESMAS TANAH
TUMBUH TC
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
82 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
25
1500000000297
26
1400000000053
27
1400000000400
28
1500000000588
JL KESEHATAN NO 20 BANGKO
KANTOR CABANG
NO
KODE PROVIDER
IKS
TELEPON
PIMPINAN
NO IKS
21447
21314
TIPE IKS
AWAL IKS
AKHIR IKS
PEMDA KERINCI
PER/08/102015
RS.TRAUMA
CENTRE
27/01/2016
30/09/2016
DR IRWAN MISWAR
PER/04/032015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
DR SAFFARUDIN
MATONDANG MPH
PER/08/2015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
PEMKAB MERANGIN
PER/03/042015
RS.TRAUMA
CENTRE
20/04/2015
19/04/2016
NAMA PROVIDER
ALAMAT
1500000000930
BP INDRATAMA MEDICA
CENTER
1400000000178
BP KESEHATAN KERJA
1500000000931
BP REZKY MEDICA
1500000001095
1500000000929
MA11222I
KODE
POS
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/16/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
DR WAHYUDI SAHADI
PER/23/062015
RS.TRAUMA
CENTRE
26/05/2015
30/04/2016
WIDIANTI
PER/19/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
BP RIZKY ASYIFA
DR. YESSY
PER/25/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
FARIDA
PER/18/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
83 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000707
PER/06/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1400000000164
DR ERDAYANA FATMA
PER/10/042015
RS.TRAUMA
CENTRE
07/04/2015
06/04/2016
1500000000706
PER/05/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1400000000166
KLINIK OPINA
DR H TRISNAWARMAN
PER/14/042015
RS.TRAUMA
CENTRE
24/04/2015
31/03/2016
10
1500000000493
KLINIK PKU
MUHAMMADIYAH PLAJU
PER/08/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
11
1400000000177
KLINIK YAZRI
DR YUDA FETTY P
PER/22/062015
RS.TRAUMA
CENTRE
26/05/2015
30/04/2016
12
1500000000962
PUSKESMAS 1 ULU
DR.HURRIAH DEWI S.
PANJAITAN
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
13
1500000001010
PUSKESMAS 11 ILIR
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
1500000001010
PUSKESMAS 11 ILIR
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
15
1500000000977
PUSKESMAS 23 ILIR
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1500000000965
PUSKESMAS 4 ULU
DR. H. NURHAYATI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
17
1500000000987
PUSKESMAS 5 ILIR
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
5612245
542628
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
84 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
18
1500000000966
PUSKESMAS 7 ULU
DR. RUSTINA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
19
1500000001013
PUSKESMAS ALANG-ALANG
LEBAR
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
20
1500000000979
PUSKESMAS ARIODILLAH
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
21
1500000000983
PUSKESMAS BASUKI
RAHMAT
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
22
1500000000989
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
23
1500000000998
PUSKESMAS BUKIT
SANGKAL
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
24
1500000000980
PUSKESMAS DEMPO
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
25
1500000000960
PUSKESMAS GANDUS
DR. APRIYANTI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
26
1500000001001
PUSKESMAS KALIDONI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
27
1500000000973
PUSKESMAS KAMPUS
DR. YULIARNI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
28
1500000000969
DR. DARLINA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
29
1500000000990
PUSKESMAS KENTEN
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
85 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
30
1500000000968
PUSKESMAS KERTAPATI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
31
1500000000963
PUSKESMAS KRAMASAN
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
32
1500000000959
PUSKESMAS MAKRAYU
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
33
1500000000978
PUSKESMAS MERDEKA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
34
1500000001003
PUSKESMAS
MULTIWAHANA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
35
1500000000970
PUSKESMAS NAGASWIDAK
DRG. BENCAS
NAINGGOLAN
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
36
1500000000964
PUSKESMAS OPI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
37
1500000000976
PUSKESMAS PADANG
SELASA
DRG. LIZANNA
FARIANTY Y
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
38
1500000000974
PUSKESMAS PAKJO
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
39
1500000000961
PUSKESMAS PEMBINA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
40
1500000000972
PUSKESMAS PLAJU
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
41
1500000001012
PUSKESMAS PUNTIKAYU
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
86 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
42
1500000000991
PUSKESMAS
SABOKINGKING
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
43
1500000001004
PUSKESMAS SAKO
DR. HERAWATI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
44
1500000000997
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
45
1500000000984
PUSKESMAS SEKIP
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
46
1500000001006
PUSKESMAS SOSIAL
DR. MERIANCE
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
47
1500000001007
PUSKESMAS SUKARAME
DRG. PURNAMAWATI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
48
1500000000975
PUSKESMAS SUNGAI
BAUNG
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
49
1500000001011
PUSKESMAS TALANG
BETUTU
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
50
1500000000981
DRG. INDRIATI
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
51
1500000000971
PUSKESMAS TAMAN
BACAAN
DRG. ERMINDA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
52
1500000000183
RS MUHAMMADIYAH
PALEMBANG
513144
PER/03/012015
RS.TRAUMA
CENTRE
14/01/2016
31/12/2016
53
1500000000183
RS MUHAMMADIYAH
PALEMBANG
513144
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
87 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
54
1400000000163
RS PELABUHAN
PALEMBANG
712840
DR DEDY NUGROHO
PER/01/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2017
55
1400000000163
RS PELABUHAN
PALEMBANG
712840
DR DEDY NUGROHO
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
56
1400000000165
RS PERTAMINA PLAJU
PALEMBANG
DR DODY ALAMSYAH
SIREGAR
PER/15/042015
RS.TRAUMA
CENTRE
29/04/2015
31/03/2016
57
1400000000200
RS TK II DR AK GANI
JL DR AK GANI NO 01
DR MADE WIRAYASA
TUSAN
PER/21/062015
RS.TRAUMA
CENTRE
20/06/2015
31/05/2016
58
1500000000597
446272
PER/12/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
59
1500000000686
RSIA YK MADIRA
364954
YAYASAN YK MAIRA
PER/11/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
60
1500000000926
KEMENKES
PER/20/052015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2016
61
1500000000300
323889
PER/04/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
62
1500000000509
RSUD SEKAYU
321855
DR IRA
PER/09/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
63
1400000000167
RUMAH SAKIT
BHAYANGKARA
PALEMBANG
DR SYAMSUL BAHAR
PER/28/062015
RS.TRAUMA
CENTRE
05/06/2015
31/05/2016
64
1500000000705
YAYASAN BUNDA
PER/07/042015
RS.TRAUMA
CENTRE
01/04/2015
30/04/2016
65
1500000000928
PER/13/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
311866
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
88 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
66
1400000000236
67
1500000001101
68
1500000001101
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
DR F X INDRA SETIADI
MARS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/24/062015
RS.TRAUMA
CENTRE
11/06/2015
31/05/2016
PER/02/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000414
KLINIK BETESDA
ROSMAWATI PURBA
PER/08/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2017
1500000000415
KLINIK MEDISTRA
ICHSANA PRANATAWATI
PER/09/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2017
1500000000650
PEMERINTAH PROVINSI
BENGKULU
PER/16/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000000862
PEMKAB BENGKULU
TENGAH
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000000298
RS BHAYANGKARA TK III
BENGKULU
341086
POLRI
PER/02/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2017
1500000000298
RS BHAYANGKARA TK III
BENGKULU
341086
POLRI
PER/02/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2017
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
89 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000982
RS TK IV 02.07.01 ZAINUL
ARIFIN
21048
KODAM II SRIWIJAYA
PER/11/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000000982
RS TK IV 02.07.01 ZAINUL
ARIFIN
21048
KODAM II SRIWIJAYA
PER/11/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001315
521118
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
10
1500000000945
75683474
PEMKAB BENGKULU
TENGAH
PER/19/05/05201
5
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
11
1500000000468
JL BHAYANGKARA BENGKULU
52004
DR. H. SYAFRIADI
PER/02/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
12
1500000000533
RSUD MUKOMUKO
71148
PEMERINTAH
KABUPATEN
MUKOMUKO
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2018
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000601
JL MERDEKA NO 12 PANGKALPINANG
1500000001511
1400000000730
BELINYU
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
DISNAKER PROVINSI
KEPULAUAN BANGKA
BELITUNG
PER/021/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/001/122015
RS.TRAUMA
CENTRE
29/01/2016
29/02/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
90 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000133
351143
PER/002/122015
RS.TRAUMA
CENTRE
29/01/2016
29/02/2016
1500000000130
21865
PER/002/122015
RS.TRAUMA
CENTRE
29/01/2016
29/02/2016
1500000000131
41771
PER/002/122015
RS.TRAUMA
CENTRE
29/01/2016
29/02/2016
1500000001400
434099
PER/019/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001509
PER/022/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001452
TANJUNG PANDAN
DR YUSTINUS
PER/023/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
10
1500000000612
PUSKESMAS BAKAM
H. SOFIANDI, SKM, M. SI
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1500000000609
H. SOFIANDI, SKM, M. SI
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
12
1500000000617
PUSKESMAS BELINYU
H. SOFIANDI, SKM, M. SI
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
13
1500000001548
PUSKESMAS BENTENG
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
14
1500000000616
PUSKESMAS GUNUNG
MUDA
BELINYU
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
15
1500000001501
PUSKESMAS JEBUS
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
H. SOFIANDI, SKM, M. SI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
91 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
16
1500000001499
PUSKESMAS KELAPA
17
1500000000607
PUSKESMAS KENANGA
SUNGAILIAT
18
1500000001549
PUSKESMAS KOBA
19
1500000001498
20
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PUSKESMAS KUNDI
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001547
PUSKESMAS LAMPUR
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
21
1500000001550
PUSKESMAS LUBUK
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
22
1500000001496
PUSKESMAS MUNTOK
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
23
1500000001544
PUSKESMAS NAMANG
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
24
1500000001543
PUSKESMAS PANGKALAN
BARU
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
25
1500000000614
PUSKESMAS PEMALI
PEMALI - BANGKA
H. SOFIANDI, SKM, M. SI
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
26
1500000000611
PUSKESMAS PENAGAN
MENDO BARAT
H. SOFIANDI, SKM, M. SI
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
27
1500000000610
PUSKESMAS PETALING
H. SOFIANDI, SKM, M. SI
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
H. SOFIANDI, SKM, M. SI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
92 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PUSKESMAS SIMPANG
KATIS
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001497
PUSKESMAS SIMPANG
TERITIP
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
30/05/2016
34
1500000000608
SUNGAILIAT
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
35
1500000001546
PER/024/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
36
1500000000606
PUSKESMAS SUNGAILIAT
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
37
1500000001500
PUSKESMAS TEMPILANG
PER/020/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
38
1400000000112
RS ALMAH
PER/015/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
39
1400000000098
RS ARSANI
PER/05/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
28
1500000000613
PUDING BESAR
29
1500000001502
PUSKESMAS PUPUT
30
1500000000615
RIAU SILIP
31
1500000001503
32
1500000001545
33
MA11222I
H. SOFIANDI, SKM, M. SI
H. SOFIANDI, SKM, M. SI
H. SOFIANDI, SKM, M. SI
H. SOFIANDI, SKM, M. SI
HIDAYAT ARSANI
4297825
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
93 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
40
1400000000097
RS BAKTI TIMAH
41
1500000000132
42
1400000000091
RS BHAKTI WARA
43
1500000000602
44
1400000000089
45
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/012/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
21008
PER/002/122015
RS.TRAUMA
CENTRE
29/01/2016
29/02/2016
422605
YAYASAM TUNAS
KARYA
PER/017/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/014/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1400000000729
PER/001/122015
RS.TRAUMA
CENTRE
29/01/2016
29/02/2016
46
1500000000619
SPGD (SISTEM
PENANGGULANGAN GAWAT
DARURAT)
SUNGAILIAT
H. SOFIANDI, SKM, M. SI
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
47
1500000001398
SUN CLINIC
PER/018/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
1500000001268
MA11222I
95837
4297888
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
KAB MUARA ENIM
PER/41/062015
TIPE IKS
RS.TRAUMA
CENTRE
AWAL IKS
08/05/2015
AKHIR IKS
07/05/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
94 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001202
JL JEND SUDIRMAN KM 35
320618
KOTA PRABUMULIH
PER/42/062015
RS.TRAUMA
CENTRE
08/06/2015
07/06/2016
1500000001075
KLINIK 3F MEDIKA
451299
DR HJ TRIKANDIANI
PER/37/052015
RS.TRAUMA
CENTRE
25/05/2015
24/05/2016
1500000000763
KLINIK FADHILAH
24102380
RS FADHILAH
PER/28/042014
RS.TRAUMA
CENTRE
05/05/2015
04/05/2016
1500000000764
68044521
DR TRISNAYANTI
PER/29/042015
RS.TRAUMA
CENTRE
05/05/2015
04/05/2016
1500000001232
69870030
MUARA ENIM
PER/44/062015
RS.TRAUMA
CENTRE
08/06/2015
07/06/2016
1500000001505
PUSKESMAS GELUMBANG
KAB. MUARA ENIM
73610770
PER/46/062015
RS.TRAUMA
CENTRE
15/06/2015
14/06/2016
1500000001231
PUSKESMAS TANJUNG
RAYA
73720427
MUARA ENIM
PER/45/062015
RS.TRAUMA
CENTRE
08/06/2015
07/06/2016
1500000000498
RS AR BUNDA
LUBUKLINGGAU
324963
DR SARAH AINAR
RAHMAN
PER/14/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
10
1500000000599
RS AR BUNDA PRABUMULIH
322954
DR H ALIP YANSON
PER/19/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
11
1500000001113
PT BUKIT ASAM
PER/40/052015
RS.TRAUMA
CENTRE
25/05/2015
24/05/2016
12
1500000000639
RS DR SOBIRIN
321013
KAB.MUSI RAWAS
PER/16/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
13
1500000000519
RS FADHILAH
3300032
DR TRISNAYANTI
PER/18/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
95 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
14
1500000000750
RS PANTI BHAKTININGSIH
CHARITAS BELITANG
824244
YAYASAN
BHAKTININGSIH
PER/31/052015
RS.TRAUMA
CENTRE
11/05/2015
10/05/2016
15
1400000000192
RS PERTAMINA
PRABUMULIH
382742
PER/21/04/2015
RS.TRAUMA
CENTRE
01/05/2015
12/04/2016
16
1500000000912
RS RUMKIT TK IV DR
NOESMIR BATURAJA
320123
OKU
PER/30/052015
RS.TRAUMA
CENTRE
11/05/2015
10/05/2016
17
1500000000535
RS SANTO ANTONIO
320395
YAYASAN SANTO
GEORGIUS
PER/35/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
18
1500000001082
RS TNI AD TK/IV.02.07.02
LAHAT
TNI AD LAHAT
PER/35/052015
RS.TRAUMA
CENTRE
18/05/2015
17/05/2016
19
1500000001073
PER/38/052015
RS.TRAUMA
CENTRE
25/05/2015
24/05/2016
20
1500000000760
320298
KAB OKU
PER/33/052015
RS.TRAUMA
CENTRE
11/05/2015
10/05/2016
21
1500000000645
RSUD LAHAT
21785
LAHAT
PER/27/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
22
1500000000536
RSUD MARTAPURA
481004
PER/22/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
23
1500000000738
67418413
OKU TIMUR
PER/20/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
24
1500000001074
PER/39/052015
RS.TRAUMA
CENTRE
25/05/2015
24/05/2016
25
1500000000544
KAB.OKU TIMUR
PER/23/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
MA11222I
450319
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
96 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
26
1500000000640
RSUD PRABUMULIH
7001085
KOTA BRABUMULIH
PER/26/042016
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
27
1500000000692
452776
LUBUK LINGGAU
PER/17/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
28
1500000000691
390487
PENUKAL ABAB
LEMATANG ILIR
PER/24/042015
RS.TRAUMA
CENTRE
13/04/2015
12/04/2016
29
1500000000856
21047
EMPAT LAWANG
PER/34/052015
RS.TRAUMA
CENTRE
18/05/2015
17/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000274
BP DARAPETAK
082177114
63
DR ELVIRA IRIANTY
PER/15/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000113
089623631
169
PER/13/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000115
KLINIK KELUARGA
PANJANG MEDIKA
081279111
659
DR AILA KARYUS
PER/16/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000503
35223
7175938
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/25/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
1400000000500
35158
3540424
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/22/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
97 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1400000000504
1400000000507
1400000000498
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7140218
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/26/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
9761738
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/28/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
7910645
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/20/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
1400000000508
KLINIK KOSASIH
TANJUNGAN
7773665
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/29/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
10
1400000000501
7641529
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/23/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
11
1400000000502
KLINIK KOSASIH
TIRTAYASA
7167635
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/24/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
12
1400000000114
KLINIK LEMATANG
MEDICAL CENTER
089631062
444
PER/14/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
13
1400000000499
7327768
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/21/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
14
1400000000497
7511491
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/19/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
15
1400000000505
7365397
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/27/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
16
1400000000496
3526413
DR.S.TRI.HERLIANTO,SH,
MH,MM,MKES
PER/18/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
17
1500000000181
RS GLADISH MEDICAL
CENTER
CV GLADISH MEDICAL
CENTER
PER/04/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
MA11222I
35116
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
98 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
18
1500000000700
704900
PER/12/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
19
1500000000401
RS MITRA HUSADA
23792
PT MITRA HUSADA
BERSAMA
PER/11/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
20
1500000000253
RS MUHAMMADIYAH
METRO
7008000
PERSYARIKATAN
MUHAMMADIYAH
PER/09/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
21
1500000000209
RS NATAR MEDIKA
92521
PER/07/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
22
1500000000218
770430
PER/08/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
23
1400000000116
RS URIP SUMOHARJO
771322
PT GUNUNG SULAH
MEDIKA
PER/10/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
24
1500000000115
RS WISMA RINI
21582
PER/01/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
25
1500000000165
703312
PROVINSI LAMPUNG
PER/05/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
26
1500000000165
703312
PROVINSI LAMPUNG
PER/05/012015
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
27
1400000000471
322160
PER/30/112015
RS.TRAUMA
CENTRE
04/01/2016
30/11/2016
28
1500000000134
RSUD PESAWARAN
KABUPATEN
PESAWARAN
PER/03/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
29
1500000000134
RSUD PESAWARAN
KABUPATEN
PESAWARAN
PER/03/012015
RS.TRAUMA
CENTRE
01/02/2016
31/01/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
99 / 322
09-02-2016
18:49:59
NO
30
KODE PROVIDER
1500000000427
KANTOR CABANG
NO
NAMA PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
DINAS TENAGA KERJA
DAN TRANSMIGRASI
PROVINSI LAMPUNG
PER/06/022015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/03/2015
AKHIR IKS
29/02/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000710
PER/009/042015
RS.TRAUMA
CENTRE
24/04/2015
23/04/2016
1500000001188
PUSKESMAS BANDAR
AGUNG
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
1500000001192
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
1500000001168
PUSKESMAS BANGUNREJO
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
1500000001181
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
1500000001182
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
1500000001189
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
1500000001179
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
100 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001164
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
10
1500000001171
PUSKESMAS GUNUNG
SUGIH
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
11
1500000001163
PUSKESMAS HAJI
PEMANGGILAN
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
12
1500000001186
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
13
1500000001165
PUSKESMAS KALIREJO
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
14
1500000001156
PUSKESMAS KARANG
ANYAR
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
15
1500000001173
PUSKESMAS KESUMADADI
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
16
1500000001196
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
17
1500000001118
DR. LINDAWATY
PER/012/052015
RS.TRAUMA
CENTRE
29/05/2015
28/04/2016
18
1500000001157
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
19
1500000001166
PUSKESMAS PONCOWARNO
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
20
1500000001191
PUSKESMAS PONCOWATI
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
101 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
21
1500000001198
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
22
1500000001197
PUSKESMAS PUNGGUR
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
23
1500000001193
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
24
1500000001183
PUSKESMAS RUMBIA
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
25
1500000001162
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
26
1500000001167
PUSKESMAS SENDANG
AGUNG
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
27
1500000001185
PUSKESMAS SEPUTIH
BANYAK
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
28
1500000001187
PUSKESMAS SEPUTIH
MATARAM
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
29
1500000001194
PUSKESMAS SEPUTIH
RAMAN
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
30
1500000001180
PUSKESMAS SEPUTIH
SURABAYA
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
31
1500000001199
PUSKESMAS SIMBAR
WARINGIN
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
32
1500000001190
PUSKESMAS SIMPANG
AGUNG
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
102 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
33
1500000001195
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
34
1500000001176
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
35
1500000001170
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
36
1500000001184
PUSKESMAS SUKO
BINANGUN
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
37
1500000001155
PUSKESMAS SURABAYA
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
38
1500000001172
PUSKESMAS TERBANGGI
SUBING
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
39
1500000001200
PUSKESMAS WATES
DR. LINDAWATY
PER / 012 /
052015
RS.TRAUMA
CENTRE
29/05/2015
28/05/2016
40
1500000000357
RS BLK METRO
PER/005/032015
RS.TRAUMA
CENTRE
05/03/2015
04/03/2016
41
1500000000651
SUNARTO, SE
PER/010/042015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2016
42
1500000000319
RS HARAPAN BUNDA
PER/007/032015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
43
1500000000318
RS ISLAM ASY-SYIFAA
PER/006/032015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
44
1400000000202
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
26766
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
103 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
45
1500000000450
RSU HANDAYANI
328399
DR. H. DJAUHARI
THALIB, M.KES
PER/008/032015
RS.TRAUMA
CENTRE
30/03/2015
29/03/2016
46
1400000000185
529898
DRG. ISMUDIJANTO
PER/014/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
47
1400000000308
RSUD MENGGALA
21131
PER/015/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001278
KLINIK PERTAMEDIKA
1500000001784
1500000001785
KLINIK PERTAMEDIKA
MEDAN SATRIA
1500000001787
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/28/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
10110
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
13110
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
KLINIK PERTAMEDIKA
MEDICAL CENTRE
SINABUNG
JL SINABUNG II NO 32 F
12110
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001789
KLINIK PERTAMEDIKA
MERDEKA TIMUR
10110
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001788
KLINIK PERTAMEDIKA
PATRA JASA
12110
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
DR NENY HERAWATI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
104 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001786
KLINIK PERTAMEDIKA
RAWAMANGUN
13110
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001790
KLINIK PERTAMEDIKA
TUGU
12120
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001783
14110
PER/47/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
10
1400000000304
PER/53/082015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
11
1500000000951
PER/30/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
12
1500000000993
PUSKESMAS KECAMATAN
CEMPAKA PUTIH
PER/36/062015
RS.TRAUMA
CENTRE
01/01/2015
31/05/2016
13
1500000001821
PUSKESMAS KECAMATAN
SENEN
10110
PER/46/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
14
1500000001826
PUSKESMAS KELURAHAN
BUNGUR
10110
PER/46/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
15
1500000001002
PUSKESMAS KELURAHAN
CEMPAKA PUTIH BARAT II
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1500000001823
PUSKESMAS KELURAHAN
KENARI
JL JAMRUD NO 22 RT 008/02
10110
PER/46/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
17
1500000001822
PUSKESMAS KELURAHAN
KRAMAT
10110
PER/46/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
18
1500000001825
PUSKESMAS KELURAHAN
KWITANG
10110
PER/46/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
4240700
DR EDI SETIAWAN
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
105 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
19
1500000001824
PUSKESMAS KELURAHAN
PASEBAN
20
1500000001005
PUSKESMAS KELURAHAN
RAWASARI
21
1400000000198
22
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/46/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
RS ISLAM JAKARTA
CEMPAKA PUTIH
PER/48/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000000328
RS MH THAMRIN SALEMBA
PER/16/032015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
23
1400000000298
RS PERTAMINA JAYA
4211911
PER/51/082015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
24
1400000000298
RS PERTAMINA JAYA
4211911
PER/01/012016
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
25
1500000000594
RS PREMIER JATINEGARA
PER/03/032015
RS.TRAUMA
CENTRE
23/03/2015
23/03/2016
26
1400000000658
RS RIDWAN MAUREKSA
PER/62/122015
RS.TRAUMA
CENTRE
01/12/2015
30/11/2016
27
1400000000351
RSIA EVASARI
4202851
PER/02/012016
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
28
1400000000351
RSIA EVASARI
4202851
PER/52/082015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
KANTOR CABANG
MA11222I
10110
DR MIRA ROZIATI
DACHLAN
DR.SRI WURYATI
HANDAYANI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
106 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
30/06/2015
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
30/06/2015
5859081
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
11110
5840451
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
11110
58902737
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PUSKESMAS KELURAHAN
KEMBANGAN SELATAN
11110
70642117
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001888
PUSKESMAS KELURAHAN
KEMBANGAN UTARA
11110
68534570
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001885
PUSKESMAS KELURAHAN
MERUYA SELATAN I
11110
68534571
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
10
1500000001886
PUSKESMAS KELURAHAN
MERUYA UTARA
11110
5843136
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
11
1500000001882
PUSKESMAS KELURAHAN
SRENGSENG
JL SRENGSENG RT 01/02
11110
68534572
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
12
1500000001710
11530
25677888
PER/14/062015
RS.TRAUMA
CENTRE
29/06/2015
30/06/2016
1500000000861
1500000001684
11110
5648379
1500000001683
PUSKESMAS KEC
PALMERAH
11110
5482370
1500000001881
PUSKESMAS KECAMATAN
KEMBANGAN
11170
1500000001884
PUSKESMAS KELURAHAN
JOGLO I
1500000001883
PUSKESMAS KELURAHAN
JOGLO II
1500000001887
MA11222I
PT SILOAM
INTERNATIONAL
HOSPITALS
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
107 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
13
1500000000516
5347411
14
1500000000088
56967788
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001023
1500000001818
RS SATYA NEGARA
1500000000497
1500000000496
1500000001614
MA11222I
TIPE IKS
AWAL IKS
AKHIR IKS
PER/06/032015
RS.TRAUMA
CENTRE
02/03/2015
29/02/2016
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KANTOR CABANG
PIMPINAN
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
4401066
RUDOLF TAMBUNAN
PER/05/2015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
64715200
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
43902350
DR R SUHARBAGYO M
PER/04/032015
RS.TRAUMA
CENTRE
19/03/2015
28/02/2016
43903355
DR KARNAIL SINGH
PER/03/032015
RS.TRAUMA
CENTRE
04/03/2015
28/02/2016
NOMOR:
PER/06/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
14250
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
108 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
7-726516517
13910
7-725640156
13320
7-722461500
13310
1500000001014
1500000001833
JL OTISTA NO 82
13110
1500000001850
PUSKESMAS KEC
MATRAMAN (TC)
1500000001707
PUSKESMAS KEC.
JATINEGARA (TC)
1500000001706
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/29/122015
RS.TRAUMA
CENTRE
21/12/2015
30/11/2016
29688716
PT NAYAKA ERA
HUSADA
PER/27/112015
RS.TRAUMA
CENTRE
21/12/2015
30/11/2016
46823314
BUDIMAN
PER/28/112015
RS.TRAUMA
CENTRE
21/12/2015
30/11/2016
DIDIK SUPARDI
PER/12/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
85903677
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
13110
8581957
DR HERNI
LESTYANINGSIH
PER/15/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
13110
8195146
DR. WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PUSKESMAS KEC.
PULOGADUNG (TC)
13110
4890519
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001837
13110
85908911
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
10
1500000001847
JL E1 MASJID BAITUSSALAM
13110
4756139
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
11
1500000001843
JL PULO ASEM IV
13110
47868535
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
12
1500000001844
JL KAPLONGAN I NO 67
13110
4786404
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
109 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
13
1500000001849
PUSKESMAS KEL
JATINEGARA KAUM
JL T BADARUDIN RT 001/05
13110
14
1500000001855
13110
15
1500000001842
13110
16
1500000001854
17
1500000001848
18
1500000001846
19
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
DR HERNI L
PER/15/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
4710423
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
13110
8507756
DR HERNI L
PER/15/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
JL GADING RAYA I
13110
4755612
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
JL H MUGENI III
13110
4756139
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001839
JL JATINEGARA TIMUR IV
13110
8511689
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
20
1500000001845
PUSKESMAS KEL
RAWAMANGUN
13110
47864411
DRG KRIS
PER/14/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
21
1500000001853
13110
85909517
DR HERNI
PER/15/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
22
1500000001851
JL KOMPL KEHAKIMAN NO 96
13110
85900059
DR HERNI
PER/15/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
23
1500000001834
JL NILAM RT 013/11
13110
8571147
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
24
1500000001835
13110
859175874
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
4755580
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
110 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1500000001841
13110
7734000
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
26
1500000001831
JL CIPINANG JAYA FF NO 8
13110
8511127
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
27
1500000001832
JL PANCAWARGA IV NO 04
13110
85909549
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
28
1500000001838
JL CIPINANG CEMPEDAK IV NO 2
13110
85909474
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
29
1500000001840
JL BB I RT 006/015
13110
7408000
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
30
1500000001836
PUSKESMAS KEL. KP
MELAYU
JL KEBON PALA I
13110
8515004
DR WINARTO
PER/13/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
31
1500000001852
JL SKIP UJUNG
13110
8500059
DR HERNI
PER/15/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
32
7-728032798
RS COLUMBIA ASIA
RAWAMANGUN
13210
29459999
PT AYUBA UTAMA
PER/30/122015
RS.TRAUMA
CENTRE
21/12/2015
30/11/2016
33
1500000000527
8617212
PER/09/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
34
7-729931841
RS KHUSUS BEDAH
RAWAMANGUN
13220
PT EL HAKIM
PER/31/122015
RS.TRAUMA
CENTRE
21/12/2015
30/11/2016
35
7-1669163483
13210
DR MARIA
PER/01/012016
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
KANTOR CABANG
MA11222I
2977 9999
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
111 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000212
83707368
ERIC SAPUTRA
PER/07/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1400000000416
83707848
ERIC SAPUTRA
PER/08/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000000147
KLINIK PRIMARINI
97265271
DR MARINI
KUSUMANINGSIH
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000459
83707368
ERIC SAPUTRA
PER/06/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001177
RS AGUNG
8294955
YAYASAN KAMAL
PER/02/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1400000000366
RS TEBET
JL MT HARYONO KAV. 13
8307540
PER/09/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
7-140332933
RS. GATSU
JL. GATSU 45
RENI
12345677
RS.TRAUMA
CENTRE
27/10/2015
30/10/2015
KANTOR CABANG
NO
KODE PROVIDER
12910
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000170
KLINIK ARAS
7869916
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000170
KLINIK ARAS
7869916
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
112 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000839
7980311
LETTY LESTARI
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000192
RS BHAYANGKARA
SESPIMMA POLRI
7650384
DR JEKSON SURUNG
SIMANJUNTAK
PER/02/022015
RS.TRAUMA
CENTRE
03/02/2015
03/02/2017
1500000000771
RS DR SUYOTO
JL RC VETERAN 178
7342012
RS DR SUYOTO
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001524
RS FATMAWATI
DI JL RS FATMAWATI CILANDAK
7501524
DR.ANDI
WAHYUNINGSIH ATTAS
PER/14/052015
RS.TRAUMA
CENTRE
15/05/2015
30/04/2016
1500000001524
RS FATMAWATI
DI JL RS FATMAWATI CILANDAK
7501524
DR.ANDI
WAHYUNINGSIH ATTAS
PER/14/052015
RS.TRAUMA
CENTRE
18/05/2015
30/04/2016
00000
RS MAYAPADA
29217777
RS MAYAPADA
PER/10/2015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
00000
RS MAYAPADA
29217777
RS MAYAPADA
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
10
1500000000721
RS MAYAPADA
29217777
RS MAYAPADA
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1500000001942
RS PRIKASIH
12430
7504669
DR SUHARNO
PER/19/082015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
12
1500000001935
RS SILOAM TB
SIMAPTUPANG
JL RA KARTINI NO 8 CILANDAK
12430
29531900
DR.IRNA S HARDIAWAN
PER/20/082015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
13
1500000000313
RSIA AULIA
7270208
DR GATOT SOERYO
KOESUMO
PER/05/2015
RS.TRAUMA
CENTRE
03/03/2015
02/03/2016
14
1500000000473
RSIA YADIKA
7291074
RAJA DL SITORUS
PER/07/2015
RS.TRAUMA
CENTRE
30/03/2015
29/03/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
113 / 322
09-02-2016
18:49:59
NO
15
KODE PROVIDER
KODE PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
12530
KEMENKES
PER/23/092015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
25/11/2015
AKHIR IKS
30/09/2016
NAMA PROVIDER
1500000001453
KANTOR CABANG
NO
RSU KECAMATAN
JAGAKARSA
7-492399683
KANTOR CABANG
NO
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
6260108
PER/06/062015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/06/2015
AKHIR IKS
31/05/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000402
081213263
286
DIKI LESTARIONO
PER/TC/02/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000355
87783668
PER/TC/04/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000324
87782670
DR.PRASETYO WIDHI
BUWONO
PER/TC/05/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000375
8480206
SRI NURYANTI
PER/TC/08/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000374
29841115
SRI NURYANTI
PER/TC/09/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
114 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000356
1500000000403
1500000000896
1500000001943
PUSKESMAS KECAMATAN
CIPAYUNG
10
1500000001962
11
1500000001963
12
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
87783668
DR.PRASETYO WIDHI
BUWONO
PER/TC/03/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
87794539
DR.DARWIN
D.TJAKRADIDJAJA
PER/TC/01/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KETUT METRIASIH
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PUSKESMAS
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
13130
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
1500000001961
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
13
1500000001964
PUSKESMAS KELURAHAN
CEGER
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
14
1500000001966
PUSKESMAS KELURAHAN
CILANGKAP
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
15
1500000001967
PUSKESMAS KELURAHAN
CIPAYUNG
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
16
1500000001959
PUSKESMAS KELURAHAN
MUNJUL
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
17
1500000001960
PUSKESMAS KELURAHAN
PONDOK RANGGON I
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
MA11222I
13110
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
115 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
18
1500000001958
PUSKESMAS KELURAHAN
PONDOK RANGGON II
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
19
1500000001965
PUSKESMAS KELURAHAN
SETU
13110
PER/13/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
20
1300000000052
RS.UKI
8092317
YAYASAN RS.UKI
PER/TC/12/0520
15
RS.TRAUMA
CENTRE
02/05/2015
02/05/2016
21
1300000000052
RS.UKI
8092317
YAYASAN RS.UKI
PER/TC/12/0520
15
RS.TRAUMA
CENTRE
02/05/2015
02/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000326
RS BHAKTI MULYA
5481625
RS BHAKTI MULYA
PER/05/032015
RS.TRAUMA
CENTRE
16/03/2015
16/03/2016
1500000000326
RS BHAKTI MULYA
5481625
RS BHAKTI MULYA
PER/05/032015
REIMBURSE
16/03/2015
16/03/2016
1400000000303
RS PELNI
5485870
PT PELNI
PER/09/092015
RS.TRAUMA
CENTRE
27/01/2016
31/12/2016
KANTOR CABANG
MA11222I
10210
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
116 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000903
PUSKESMAS KECAMATAN
PENJARINGAN
6694917
FLORIDA MASNIARI S
PER/01/TC/0520
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000902
PUSKESMAS KELURAHAN
KAMAL MUARA
55959125
DR INDRA DARMA
PER/01/TC/0520
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000901
PUSKESMAS KELURAHAN
KAPUK MUARA
JL KAPUK KAMAL NO 28
6678173
DRG WIDYANINGSIH
PER/01/TC/0520
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000897
PUSKESMAS KELURAHAN
PEJAGALAN
6616245
PER/01/TC/0520
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000899
PUSKESMAS KELURAHAN
PENJARINGAN I
669377
TRI
PER/01/TC/0520
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000900
PUSKESMAS KELURAHAN
PLUIT
JL MUARA ANGKE
6678173
PER/01/TC/0520
15
RS.TRAUMA
CENTRE
01/05/2015
31/05/2016
1500000000898
PUSKESMAS PENJARINGAN
II
66696407
KEMALA
PER/01/TC/0520
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1300000000038
RS ATMAJAYA
JL PLUIT RAYA NO 2
6606127
YAYASAN ATMAJAYA
PER/02/TC/0520
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
1500000001828
MA11222I
NAMA PROVIDER
KLINIK AL HUSAENI
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
081707997
49
DR HJ SITI MAKIAH
PER/22/072015
TIPE IKS
RS.TRAUMA
CENTRE
AWAL IKS
01/08/2015
AKHIR IKS
31/07/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
117 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/012/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
021559641
17
PER/011/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
7311750
PER/014/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
DR HARYANI
PER/010/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
DR DEDDY DASUKI,
MARS
PER/024/102015
RS.TRAUMA
CENTRE
30/11/2015
31/10/2016
081777075
3
PER/ 009
/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
5447798
DR ATHENAWATI
UNANG
PER/013/062015
KAPITASI
01/06/2015
31/05/2016
DR ATHENAWATI
UNANG
PER/013/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
KLINIK PRATAMA MH
THAMRIN CENGKARENG
PER/003/012016
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
1500000001812
KLINIK PRATAMA MH
THAMRIN KALIDERES
DR SITI MAKIAH
PER/015/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1400000000530
SRI NURYANTI
PER/027/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000001261
1500000001262
1500000001265
1500000001264
KLINIK DR HARYANI
7-587445633
1500000001263
07321
1500000001288
10
1500000000145
KLINIK PRATAMA MH
THAMRIN CENGKARENG
11
1500000000145
12
13
MA11222I
15211
11110
5456027
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
118 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
14
7-757562796
15141
SRI NURYANTI
PER/027/102015
RS.TRAUMA
CENTRE
02/12/2015
30/09/2016
15
7-589033023
11710
DR SAPTAJI
PER/025/102015
RS.TRAUMA
CENTRE
30/11/2015
31/10/2016
16
7-1459450363
11710
DR I ICHSAN HANAFI
MARS
PER/004/012016
RS.TRAUMA
CENTRE
22/01/2016
17/01/2017
17
1500000000146
RS KARANG TENGAH
MEDIKA
7336699
PER/01/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
18
1500000000146
RS KARANG TENGAH
MEDIKA
7336699
PER/005/012016
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
19
1500000001260
RS MITRA HUSADA
082125449
938
DR HENDRY WIJAYA
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
20
1400000000006
RSUD CENGKARENG
54382793
DR SUGINO KESUMA
PER/033/122015
RS.TRAUMA
CENTRE
30/12/2015
30/11/2016
21
1500000001976
021706107
35
DR ELIYANAH
PER/01/RSTC/10
2015
RS.TRAUMA
CENTRE
15/10/2015
14/10/2016
KANTOR CABANG
NO
KODE PROVIDER
1500000000841
MA11222I
NAMA PROVIDER
PUSAT PELATIHAN KERJA
PENGEMBANGAN INDUSTRI
(PPKPI) PASAR REBO
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
8400724
SUMINARSIH WAGE
PER/06/052015
TIPE IKS
RS.TRAUMA
CENTRE
AWAL IKS
01/05/2015
AKHIR IKS
30/04/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
119 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001859
PUSKESMAS KECAMATAN
CAKUNG
13930
4614700
PER/12/072015
FFS
06/07/2015
30/06/2016
1500000001861
PUSKESMAS KELURAHAN
CAKUNG BARAT
13910
46829709
PER/12/072015
FFS
06/07/2015
30/06/2016
1500000001863
PUSKESMAS KELURAHAN
CAKUNG TIMUR
JL BALAI RAKYAT NO 87
13910
4682910
PER/12/072015
FFS
06/07/2015
30/06/2016
1500000001867
PUSKESMAS KELURAHAN
JATINEGARA
JL RAYA BEKASI KM 17
13920
4612345
PER/12/072015
FFS
06/07/2015
30/06/2016
1500000001868
PUSKESMAS KELURAHAN
PENGGILINGAN ELOK
13920
4807827
PER/12/072015
FFS
06/07/2015
30/06/2016
1500000001864
PUSKESMAS KELURAHAN
PENGGILINGAN PIK
13940
46829710
PER/12/072015
FFS
06/07/2015
30/06/2016
1500000001865
PUSKESMAS KELURAHAN
PULOGEBANG
13940
4807828
PER/12/072015
FFS
06/07/2015
30/06/2016
1500000001862
PUSKESMAS KELURAHAN
RAWA TERATAI
13920
46829720
PER/12/072015
FFS
06/07/2015
30/06/2016
10
1500000001860
PUSKESMAS KELURAHAN
UJUNG MENTENG
13960
46828217
PER/12/072015
FFS
06/07/2015
30/06/2016
11
1500000000247
RS ANTAM MEDIKA
JL RAYA PEMUDA NO 1A
29378939
PER/TC/01/0320
15
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
12
7-1362178499
RS HARAPAN JAYAKARTA
PER/TC/01/0120
16
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
13
1200000000004
RS HARAPAN JAYAKARTA
PER/TC/01/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
13210
46822879
4603916
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
120 / 322
09-02-2016
18:49:59
NO
14
KODE PROVIDER
KODE PROVIDER
RS GANDARIA
KODE PROVIDER
NAMA PROVIDER
1500000000656
1500000000591
RS ISLAM JAKARTA
SUKAPURA
1500000000290
RS. FIRDAUS
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
8610471
PER/11/052015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/06/2015
AKHIR IKS
31/05/2016
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
7203311
05/042015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/04/2015
AKHIR IKS
01/04/2016
KANTOR CABANG
ALAMAT
NAMA PROVIDER
1500000000476
KANTOR CABANG
NO
1100000000029
KANTOR CABANG
NO
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
4303619
DR.EMPAT PATONAH
4400781
KOMP BEA CUKAI JL SIAK J5/14 JAKARTA
UTARA
4407322
DR UNTUNG SUGIHARTO
TIPE IKS
AWAL IKS
AKHIR IKS
02/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/02/04015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/01/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
121 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
1500000001347
PUSKESMAS KECAMATAN
TAMANSARI
6247319
1500000001350
PUSKESMAS KELURAHAN
KEAGUNGAN
1500000001362
PUSKESMAS KELURAHAN
KRUKUT
1500000001349
TIPE IKS
AWAL IKS
AKHIR IKS
PER/007/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
6281130
PER/007/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
JL KRUKUT LIO
6319817
PER/007/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PUSKESMAS KELURAHAN
MANGGA BESAR
JL BLUSTRU NO.16
6595342
PER/007/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001351
PUSKESMAS KELURAHAN
MAPHAR
JL KEBON JERUK X
6592603
PER/007/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001348
PUSKESMAS KELURAHAN
TAMANSARI
6247319
DR HERWIN M
PER/007/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000596
RSU KECAMATAN
PADEMANGAN
6452346
DR SITI RACHMI
PER/005/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
DR HERWIN
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
2015000000001
5207797
2015000000002
RS JAKARTA
5732241
MA11222I
DR HERWIN MEIFENDY
PT JASMETRA
TIPE IKS
AWAL IKS
AKHIR IKS
PER/TC/08/0120
15
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
001/MKT/IKSMITRA/3/2015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
122 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1502201500002
78840267
PER/03/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
1806201500004
RS ZAHIRAH
7872210
ROBI HARI
SETIAWAN,SE,MM
PER/12/062015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1806201500004
RS ZAHIRAH
7872210
ROBI HARI
SETIAWAN,SE,MM
001/RSZDIR/PKS/VI/201
5
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
2505201500003
RSU KECAMATAN
MAMPANG PRAPATAN
79192187
PER/09/052015
RS.TRAUMA
CENTRE
21/05/2015
20/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001896
40114
7271451
NENDEN SUHARTINI
PER/25/0715
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1500000001896
40114
7271451
NENDEN SUHARTINI
PER/01/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
1500000000837
4201596
PT KIMIA FARMA
(PERSERO) TBK
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000837
4201596
PT KIMIA FARMA
(PERSERO) TBK
PER/09/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
1500000000834
JL.IR.H.JUANDA 69 BANDUNG
4203331
PT KIMIA FARMA
(PERSERO) TBK
PER/11/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
123 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000834
JL.IR.H.JUANDA 69 BANDUNG
4203331
PT KIMIA FARMA
(PERSERO) TBK
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000835
JL.SETIABUDI 36 BANDUNG
2038048
PT KIMIA FARMA
(PERSERO) TBK
PER/12/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
1500000000835
JL.SETIABUDI 36 BANDUNG
2038048
PT KIMIA FARMA
(PERSERO) TBK
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000836
7178664
PT KIMIA FARMA
(PERSERO) TBK
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
10
1500000000836
7178664
PT KIMIA FARMA
(PERSERO) TBK
PER/13/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
11
1500000000859
87805328
YUDI PRIHARTANTO
PER/02/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
12
1500000000859
87805328
YUDI PRIHARTANTO
PER/15/ 042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
13
1500000000860
KLINIK AMANAH
7279705
YUDI PRIHARTANTO
PER/03/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
14
1500000000860
KLINIK AMANAH
7279705
YUDI PRIHARTANTO
PER/18/ 052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
15
1500000000805
7801861
DR H YONO SUDIYONO
MARS, MHKES
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
16
1500000000805
7801861
DR H YONO SUDIYONO
MARS, MHKES
PER/16/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
17
1500000000855
KLINIK HIKMAH
814 254 80
PER/05/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
124 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
18
1500000000855
KLINIK HIKMAH
814 254 80
PER/12/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
19
1500000000854
81525480
NANO ROHANA
PER/06/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
20
1500000000854
81525480
NANO ROHANA
PER/13/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
21
1500000000585
KLINIK ITENAS
PT. RS PADJADJARAN
PER/07/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
22
1500000000585
KLINIK ITENAS
PT. RS PADJADJARAN
PER/004/04/2015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
23
1500000000584
7564929
PT RUMAH SAKIT
PADJADJARAN
PER/03/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
24
1500000000584
7564929
PT RUMAH SAKIT
PADJADJARAN
PER/08/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
25
1500000000833
7305019
PT KIMIA FARMA
(PERSERO) TBK
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
26
1500000000833
7305019
PT KIMIA FARMA
(PERSERO) TBK
PER/10/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
27
1500000000553
7804489
MULYATI
PER/05/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
28
1500000000553
7804489
MULYATI
PER/14/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
29
1500000000704
7237337
DRG YUDHIASTUTI
NUNING HARINI
PER/08/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
125 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
30
1500000000704
7237337
DRG YUDHIASTUTI
NUNING HARINI
PER/15/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
31
1500000000600
88881585
DR MAGDALIZA
PER/16/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
32
1500000000600
88881585
DR MAGDALIZA
PER/06/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
33
1500000000853
91752269
DR HARIS FATAH
PER/17/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
34
1500000000853
91752269
DR HARIS FATAH
PER/14/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
35
1500000000743
7208284
PER/18/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
36
1500000000743
7208284
PER/10/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
37
1500000000708
081563944
143
PER/09/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
38
1500000000708
081563944
143
PER/19/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
39
1500000000801
RS MATA CICENDO
4231280
KEMENKES
PER/11/042015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
40
1500000000801
RS MATA CICENDO
4231280
KEMENKES
PER/20/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
41
1100000000014
RS PINDAD
7322468
PER/21/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
126 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
42
1100000000014
RS PINDAD
43
1100000000015
RS SARININGSIH
44
1100000000015
45
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PER/22/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
RS SARININGSIH
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000001399
RS. SALAMUN
2032090
DR. BAMBANG S.
GUNADI, SP.RAD., MARS.,
PER/20/ 052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
46
1500000001399
RS. SALAMUN
2032090
DR. BAMBANG S.
GUNADI, SP.RAD., MARS.,
PER/23/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
47
1400000000159
7208172
PERKUMPULAN
"PERHIMPUNAN SANTO
BORROMEUS"
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
48
1500000001934
40115
4206061
PROF DR M AHMAD
DJOJOSUGITO, DR, SP OT
PER/24/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
49
1500000001934
40115
4206061
PROF DR M AHMAD
DJOJOSUGITO, DR, SP OT
PER/27/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
50
1500000000697
RSU BUNGSU
4231550
PER/07/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
51
1500000000697
RSU BUNGSU
4231550
PER/25/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
52
1500000000460
7811794
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
53
1500000000460
7811794
PER/26/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
MA11222I
7322468
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
127 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
54
1500000001936
40161
2034953
KEMENKES
PER/27/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
55
1500000001936
40161
2034953
KEMENKES
PER/27025015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000698
KLINIIK TC ANNISA
PER/17/052015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
1500000000698
KLINIIK TC ANNISA
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000352
JL SILIWANGI KM 12 NAROGONG
BT.GEBANG
TATI NURHAYATI
PER/49/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
1500000000830
ALAN
PER/24/052015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
1500000000830
ALAN
PER/24/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001938
KLINIK TC CEMPAKA
MEDICAL CENTER
PER/34/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
1500000000699
KLINIK TC HANDAYANI
MEDIKA
PER/18/052015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
MA11222I
32960966
17216
8807111
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
128 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000699
KLINIK TC HANDAYANI
MEDIKA
1400000000356
10
1500000000744
KLINIK TC MAHADINA
11
1500000000744
12
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/18/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/35/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
PER/22/052015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
KLINIK TC MAHADINA
PER/22/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000739
KLINIK TC MAHADINA
MEDIKA
PER/21/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
13
1400000000359
KLINIK TC MEDIKA
HARMONY
PER/51/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
14
1500000000913
KLINIK TC MH THAMRIN
BEKASI
PER/25/052015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
15
1500000000913
KLINIK TC MH THAMRIN
BEKASI
PER/25/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
16
1400000000355
88987741
PER/35/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
17
1400000000354
KLINIK TC NAYAKA 01
BEKASI
88958142
PER/37/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
18
1400000000353
KLINIK TC NAYAKA 04
BEKASI
89132587
PER/37/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
19
1500000001328
PER/30A/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
8862936
89110027
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
129 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
20
1500000001328
PER/30A/062015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
21
1500000001327
PER/30B/062015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
22
1500000001327
PER/30B/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
23
1500000001326
PER/30C/062015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
24
1500000001326
PER/30C/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
25
1500000001254
KLINIK TC SRITINA
PER/28/062015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
26
1500000001254
KLINIK TC SRITINA
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
27
1500000000745
PER/20/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
28
1400000000358
KLINIK TC WIRATAMA
88326918
PER/50/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
29
1400000000357
JL RAYA NAROGONG KM 7 NO 45
8253516
M SYAFI'I MA'ARIF
PER/35/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
30
1500000001947
RS TC BUNDA MULIA
8900579
DIONISIUS SAGIGATA
YASIDA LAWING, ST
PER/47/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
31
1400000000120
88882211
PT ANNA MEDIKA
PER/23/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
17520
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
130 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
32
1400000000365
8868888
33
1400000000715
RSTC BELLA
8801775
34
1400000000121
88323444
35
1400000000121
36
1400000000121
37
7-1086708933
JL KEMAKMURAN NO 39 MARGAJAYA
BEKASI
38
7-976111831
39
1500000001968
40
AWAL IKS
AKHIR IKS
PER/36/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
PER/59/122015
RS.TRAUMA
CENTRE
01/12/2015
31/12/2016
PER/01/012016
RS.TRAUMA
CENTRE
09/02/2016
31/12/2016
88323444
PER/19/052015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2015
88323444
PER/19/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
17133
PER/61/122015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
17141
PER/60/122015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
17217
PER/55/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
1100000000020
8221570
JOHANES POSO
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
41
1100000000020
8221570
JOHANES POSO
PER/02/012016
RS.TRAUMA
CENTRE
09/02/2016
31/12/2016
42
1100000000020
8221570
JOHANES POSO
PER/27/062015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2015
43
1500000000681
29493400
DR NOVITA
PER/01/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
DR DINI HANDAYANI
MARS
TIPE IKS
82651212
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
131 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
44
1500000001251
45
7-976569533
46
1500000001329
47
1500000001817
48
1500000001255
JL RAYA BABELAN
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
17155
17111
TIPE IKS
AWAL IKS
AKHIR IKS
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/58/122015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/33/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000252
295333182
CV BATIK ESTETIKA
INDONESIA
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
1500000000252
295333182
CV BATIK ESTETIKA
INDONESIA
PER/16/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
1400000000415
BP BUNDA MULIA
5978058
HJ UPEN SUPENTI
PER/07/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
1400000000415
BP BUNDA MULIA
5978058
HJ UPEN SUPENTI
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
132 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000073
BP NURDIN WAHID
JL HM ASHARI NO 22 CIBINONG
87916739
YANNI MAUTIA S R
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000073
BP NURDIN WAHID
JL HM ASHARI NO 22 CIBINONG
87916739
YANNI MAUTIA S R
PER/12/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
7-1588689223
JL.LANDBAW NO.01
16810
87902900
SUSINAH HARUN
PER/22/012016
RS.TRAUMA
CENTRE
04/02/2016
31/12/2016
7-1588689227
KLINIK MH THAMRIN
16770
025182561
72
YAYASAN MH THAMRIN
PER/25/012016
RS.TRAUMA
CENTRE
04/02/2016
31/12/2016
1400000000311
DR JUNAIDY FREDY
PER/23/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
10
7-1670259391
DRG.WIWIK DWI
ARYANI, MARS
PER/24/012016
RS.TRAUMA
CENTRE
04/02/2016
31/12/2016
11
1500000001536
PUSKESMAS JASINGA
JL.LET.SAYUTI JASINGA
085780041
002
PER/21/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
12
1500000001536
PUSKESMAS JASINGA
JL.LET.SAYUTI JASINGA
085780041
002
PER/26/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
13
1400000000310
RS ATANG SANJAYA
7532946
AURI
PER/04/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
14
1400000000310
RS ATANG SANJAYA
7532946
AURI
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
15
1500000000314
RS BHAYANGKARA TK IV
BOGOR
8348987
POLRI
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
16
1500000000314
RS BHAYANGKARA TK IV
BOGOR
8348987
POLRI
PER/17/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
MA11222I
16810
87952811
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
133 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1200000000006
RS BINA HUSADA TC
87911000
DR HARSONO
PER/01/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
18
1200000000006
RS BINA HUSADA TC
87911000
DR HARSONO
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
19
1500000000071
RS FAMILY MEDICAL
CENTER TC
PT JALAMAS PUTRA
REJEKI
PER/10/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
20
1500000000071
RS FAMILY MEDICAL
CENTER TC
PT JALAMAS PUTRA
REJEKI
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
21
1400000000286
RS ISLAM BOGOR
8316822
PER/26/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
22
1400000000284
8626868
PER/02/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
23
1400000000284
8626868
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
1400000000713
RS MELANIA
8321196
PT SPAA MEDIKA
PER/09/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
25
1400000000713
RS MELANIA
8321196
PT SPAA MEDIKA
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
1500000000074
RS PMI BOGOR TC
JL PAJAJARAN NO 80
YAYASAN PMI
PER/13/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
27
1500000000074
RS PMI BOGOR TC
JL PAJAJARAN NO 80
YAYASAN PMI
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
28
1400000000309
RS SALAK BOGOR
JL JENDRAL SUDIRMAN NO 8
KESDAM SILIWANGI
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
8344609
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
134 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
29
1400000000309
RS SALAK BOGOR
JL JENDRAL SUDIRMAN NO 8
8344609
KESDAM SILIWANGI
PER/03/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
30
1500000000072
RS SENTRA MEDIKA
CIBINONG TC
87909999
DRG HERMAN
PER/11/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
31
1500000000072
RS SENTRA MEDIKA
CIBINONG TC
87909999
DRG HERMAN
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
32
1400000000333
RS TRIMITRA
8763055
DR EMA SUMARSAH
PER/05/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
33
1400000000333
RS TRIMITRA
8763055
DR EMA SUMARSAH
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
34
1500000000637
RS VANIA
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
35
1500000000637
RS VANIA
PER/19/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
36
1500000000075
RSD CIBINONG TC
PER/14/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
37
1500000000075
RSD CIBINONG TC
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
38
1500000000636
RSIA ANNISA
YYS ANNISA
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
39
1500000000636
RSIA ANNISA
YYS ANNISA
PER/18/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
40
1500000001535
PER/25/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
MA11222I
081211012
84
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
135 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
41
1500000001535
081211012
84
PER/20/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
42
1500000001535
081211012
84
PER/25/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
43
1400000000442
DR TRIWANDHA ELAN
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
44
1400000000442
DR TRIWANDHA ELAN
PER/08/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
45
1500000000230
RUMAH SAKIT
PERTAMEDIKA SENTUL
CITY
29672977
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
46
1500000000230
RUMAH SAKIT
PERTAMEDIKA SENTUL
CITY
29672977
PER/15/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
47
1400000000414
SALSABILLA MEDICAL
CENTRE
87905768
PER/06/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
48
1400000000414
SALSABILLA MEDICAL
CENTRE
87905768
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
1400000000525
MA11222I
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
8300223
PT NAYAKA ERA
HUSADA
PER/004/122014
TIPE IKS
RS.TRAUMA
CENTRE
AWAL IKS
01/01/2015
AKHIR IKS
30/11/2015
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
136 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001053
DR. DEDEN
PER/006/042015
FFS
01/05/2015
30/04/2017
1500000001055
PKM ASTANAJAPURA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001076
PKM ASTANALANGGAR
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
FFS
01/05/2015
30/04/2017
1500000001077
PKM ASTAPADA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001078
PKM BABAKAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001079
PKM BEBER
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001080
PKM BUNDER
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001081
PKM CIBOGO
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
10
1500000001083
PKM CILEDUG
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
11
1500000001220
PKM CIPERNA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
12
1500000001221
PKM CIWARINGIN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
13
1500000001084
PKM DUKUPUNTANG
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
MA11222I
832059
616028
661091
342358
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
137 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
14
1500000001222
PKM GEBANG
15
1500000001085
PKM GEGESIK
16
1500000001086
PKM GEMBONGAN
17
1500000001087
18
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
PKM GEMPOL
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001088
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
19
1500000001089
PKM JAGAPURA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
20
1500000001091
PKM JEMARAS
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
21
1500000001092
PKM KALIBUNTU
663363
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
22
1500000001093
PKM KALIWEDI
357185
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
23
1500000001223
PKM KAMARANG
324025
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
24
1500000001094
PKM KARANGSARI
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
25
1500000001096
PKM KARANGSEMBUNG
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
MA11222I
357788
635600
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
138 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
26
1500000001097
PKM KEDATON
27
1500000001098
PKM KEDAWUNG
28
1500000001099
PKM KEPUH
29
1500000001100
PKM KLANGENAN
30
1500000001102
PKM KUBANGDELEG
31
1500000001103
PKM LOSARI
JL. H. DULNGALIM
32
1500000001105
PKM LURAH
33
1500000001106
PKM MAYUNG
34
1500000001107
35
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
831604
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
244505
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
PKM MUNDU
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
1500000001108
PKM PABUARAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
36
1500000001109
PKM PALIMANAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
37
1500000001110
PKM PANGENAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
MA11222I
487795
341363
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
139 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
38
1500000001111
PKM PANGKALAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
39
1500000001112
PKM PANGURAGAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
40
1500000001114
PKM PASALEMAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
41
1500000001115
PKM PLERED
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
42
1500000001116
PKM PLUMBON
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
43
1500000001117
PKM SEDONG
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
44
1500000001119
PKM SENDANG
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
45
1500000001120
PKM SIDAMULYA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
46
1500000001121
PKM SINDANGJAWA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
47
1500000001122
PKM SINDANGLAUT
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
48
1500000001135
PKM SUMBER
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
49
1500000001134
PKM SURANENGGALA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
140 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
50
1500000001132
PKM SUSUKAN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
51
1500000001131
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
52
1500000001130
PKM TALUN
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
53
1500000001129
PKM TEGALGUBUG
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
54
1500000001128
PKM TERSANA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
55
1500000001127
PKM WALED
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
56
1500000001126
PKM WANGUNHARJA
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
57
1500000001125
PKM WARUROYOM
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
58
1500000001124
PKM WATUBELAH
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
59
1500000001123
PKM WINONG
DINAS KESEHATAN
KABUPATEN CIREBON
PER/007/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2017
60
0900000000017
PER/002/003201
5
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
61
1500000000474
RSTC CIDERES
PER/003/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
0233661003
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
141 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
31/12/2015
206330
PER/005/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
281043
PER/008/052015
FFS
01/05/2015
30/04/2017
PER/009/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
PER/004/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
JL KESAMBI NO.237
201861
63
1500000000618
64
1500000001051
RSTC MAJALENGKA
65
0600000000001
66
0900000000019
KODE PROVIDER
AKHIR IKS
01/01/2015
RSTC CIREMAI
NO
AWAL IKS
RS.TRAUMA
CENTRE
0900000000018
TIPE IKS
PER/001/012015
62
KANTOR CABANG
PIMPINAN
871565
TNI AD
YAYASAN WIJAYA
KUSUMAH
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001928
KLINIK AFIQAH
29878013
PER/50/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001206
JL KH HASYIM ASHARI NO 31 C
TANGERANG
46708434
DRG SUGIHARTINI
PER/39/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000000988
23693773
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000000996
5518867
DR. H. R. HANDAYA
DIPANEGARA, M.KES,
SPAK
PER/32/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
142 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000985
90329972
DR. DARSONO
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001016
95847058
PER/35/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001017
55798985
AGUS JAELANI
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001244
5520870
DR ALFI RAHMAH
PER/42/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001241
5502676
YAYASAN PARTUHA
PER/43/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
10
1500000001712
TITIK SURYATI
PER/46/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
11
1500000001205
PER/40/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001711
TITIK SURYATI
PER/47/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
13
1500000001283
KLINIK NURBAYAN
DR. MOH.
KHAERUMANSYAH
PER/44/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
14
1500000001015
118754
MIFTAHUL ULUM
PER/34/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
15
1500000000994
KLINIK PRADHANA
54380703
PER/30/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
16
1500000000995
KLINIK PRASHANTI
5525365
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
5522007
15211
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
143 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1500000001204
5911830
DR SOLAIMAN BUDIMAN
PER/41/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
18
1500000000992
83666559
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
19
1500000000999
7323207
LILLYANA LOKANANTA
PER/33/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
20
1500000001133
85145757
KUNADI SETIONO
PER/37/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
21
1500000001158
54213590
PER/38/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
22
1500000001159
MAYAPADA HOSPITAL
TANGERANG
55781888
DR. DEDI
TEDJAKUSNADI, MARS
PER/26/052015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
23
1500000001159
MAYAPADA HOSPITAL
TANGERANG
55781888
DR. DEDI
TEDJAKUSNADI, MARS
PER/68/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
24
1400000000650
RS BHAKTI ASIH
7305662
PER/67/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
25
1400000000652
7333430
PER/17/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
1400000000652
7333430
PER/66/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
27
1400000000651
5522794
PER/65/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28
1400000000651
5522794
PER/18/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
144 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
29
1400000000655
5460055
PT. SILOAM
INTERNATIONAL
HOSPITALS
PER/16/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
30
1400000000655
5460055
PT. SILOAM
INTERNATIONAL
HOSPITALS
PER/69/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
31
1400000000653
JL DAAN MOGOT 59
5523551
TNI AD
PER/15/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
32
1500000000465
55752575
PER/64/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
33
1500000000465
55752575
PER/21/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001294
200160
PER/12/042015
RS.TRAUMA
CENTRE
01/04/2015
30/03/2016
1500000001319
BERTHA MEDIKA
081768386
47
DR HALILI SANUSI
PER/41/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000330
BP PERMATA HUSADA
WAWAN MULYANA
PER/07/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000330
BP PERMATA HUSADA
WAWAN MULYANA
PER/07/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
145 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001276
782537
MARDANI SJOFJAN
PER/17/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001306
087771253
335
DR.H.ACHMAD
KHOMRUDIN
PER/37/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001307
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001274
KLINIK AL BAROKAH
087771652
567
MASITOH
PER/19/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001298
KLINIK AL FURQON
081294600
11
PER/46/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000001474
087871603
977
DR LENNY
PER/071/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
1500000001482
087771634
586
PER/063/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
12
1500000001311
087808192
103
IIS ISNAWATI
PER/33/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
13
1500000001313
085216679
543
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
1500000001290
081886360
4
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
15
1500000001277
10820940
DR ANDRI HAVYATRA
LUBIS
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1500000001293
KLINIK AR-ROHMAN
5282828
DR. GHOZI
PER/30/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
146 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1500000001303
KLINIK AVIVA
087771372
393
HJ VENI
PER/40/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
18
1500000001299
087774495
520
AGUS KHOMEINI
PER/42/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
19
1500000001305
081896727
7
DR. A HASANUDIN
PER/38/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
20
1500000001297
081289414
44
DR RENITHA S TARBIN
PER/047/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
21
1500000001292
KLINIK BOUGENVILLE
CIEKEK
081281552
16
ARIEF
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
22
1500000001475
KLINIK BUCHORI
081218717
666
DR. BUCHORI
PER/070/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
23
1500000001472
081291975
941
SUIBAH
PER/073/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
24
1500000001267
KLINIK DIFA
085780622
081
DIDI MULYADI
PER/24/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
25
1500000001467
085254259
386
PER/078/062015
RS.TRAUMA
CENTRE
01/05/2016
31/05/2016
26
1500000001468
081118376
72
DR. FAIQOH
PER/077/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
27
1500000001455
KLINIK FATAHILLAH
MEDIKA
087771301
685
YYS FATAHILAH
PER/060/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
28
1500000001321
087771376
586
DR. DANANG
PER/051/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
147 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
29
1500000001273
082311921
355
MARLENA HARTATI
PER/20/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
30
1500000001270
081234040
715
MARLENA HARTATI
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
31
1500000001456
087778553
595
PER/059/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
32
1500000001322
DRG H HABIBULLAH
PER/049/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
33
1500000001471
087771305
005
DR TETI ENDRIANI
PER/074/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
34
1500000001291
081281980
708
DRG LUSIANA
ISKANDAR
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
35
1500000001320
KLINIK INSANI
085610063
42
DR M. YUSTIANA
PER/050/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
36
1500000000331
573756
DR ISNAYATI
PER/08/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
37
1500000000331
573756
DR ISNAYATI
PER/08/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
38
1500000001473
KLINIK JANNAH 2
081112534
21
ADE
PER/072/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
39
1500000001479
081316277
013
PER/066/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
40
1500000001301
KLINIK KAGUNGAN
081295614
14
TITIK SUHAYATI
PER/44/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
148 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
41
1500000001310
KLINIK KHOIRUNNISA
081316206
264
PER/34/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
42
1500000001271
087781512
539
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
43
1500000001469
081789707
5
PT KIMIA FARMA
APOTEK
PER/076/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
44
1500000001470
081213450
55
PT KIMIA FARMA
APOTEK
PER/075/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
45
1500000000254
KLINIK MEDIKA
209975
DR. DIANAHAN
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
46
1500000000254
KLINIK MEDIKA
209975
DR. DIANAHAN
PER/05/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
47
1500000001459
081399090
915
DR. MUHAIMIN
PER/056/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
48
1500000000107
400554
PT MODERN MEDIKA
PER/03/022015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
49
1500000000107
400554
PT MODERN MEDIKA
PER/03/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
50
1500000001304
081316372
239
PER/39/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
51
1500000001458
KLINIK MUCHIB'BAT
081319531
937
BD. ELLA
PER/057/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
52
1500000001461
KLINIK MULTAZAM
087772826
045
DR. IFAD
PER/062/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
149 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
53
1500000001275
17063774
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
54
1500000001296
KLINIK NURHIKMAT
089888434
24
PER/048/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
55
1500000001300
ROHMAWATI
PER/45/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
56
1500000001476
087851215
003
SUHARTININGSIH
PER/069/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
57
1500000001312
087772188
889
AEP SAEFULLOH
PER/32/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
58
1500000001266
081886306
4
ANGGIT VIRGIAWAN
PER/25/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
59
1500000001460
087871177
603
BD. MAMAH
PER/055/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
60
1500000001464
JL RAYA TAKTAKAN 66
081316627
405
DR. RAHMAT F
PER/053/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
61
1500000001457
KLINIK SAKINAH
087771791
609
PER/058/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
62
1500000001462
081323209
449
PER/054/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
63
1500000001465
081296227
89
YENI SUTANTO
PER/052/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
64
1500000000255
223992
PER/06/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
150 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
65
1500000000255
223992
PER/06/032015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
66
1500000001302
081311361
619
NURLAELAH
PER/43/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
67
1500000001481
085775665
451
ELLA
PER/064/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
68
1500000001308
081395549
666
H.MULYADI
PER/35/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
69
1500000001477
089839689
88
DR. MUSLIH
PER/068/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
70
1500000001454
087771648
361
DR HUSEIN
PER/061/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
71
1500000001272
081316224
653
MARLENA HARTATI
PER/21/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
72
1500000001269
081381562
420
PER/23/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
73
1500000001478
081314868
269
DR. ROSTIATI
PER/067/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
74
1500000001480
082110400
818
PER/065/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
75
1500000000329
RS HERMINA CIRUAS
280555
HERMINA HOSPITAL
GROUP
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
76
1500000000329
RS HERMINA CIRUAS
280555
HERMINA HOSPITAL
GROUP
PER/09/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
151 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
77
1500000000086
220022
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
78
1500000000086
220022
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
79
1500000001257
391161
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
80
1400000000082
RSUD BANTEN
8490911
PROVINSI BANTEN
PER/010/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
81
1500000000244
376433
RSUD ADJIDARMO
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
82
1500000000244
376433
RSUD ADJIDARMO
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
83
1400000000320
RSUD SERANG
42111
200528
KOTA SERANG
PER/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
84
1400000000320
RSUD SERANG
42111
200528
KOTA SERANG
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
85
1500000001256
232648
PER/15/06/2015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
152 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001894
BLUD RS SEKARWANGI
1500000001937
1400000000244
1400000000254
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/08/TC/0820
15
RS.TRAUMA
CENTRE
01/08/2015
31/07/2016
244046
PER/12/TC/0820
15
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
733767
PER/10/TC/0820
15
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
JL PELABUHAN 2 KM 13 KP CIBODAS RT
03/04 DS KERTARAHARJA CIKEMBAR
324417
DR NASOKA RAMLI
PER/09/TC/0820
15
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1400000000295
KLINIK PADJAJARAN
ASSALAM
PER/17/TC/1220
15
RS.TRAUMA
CENTRE
29/12/2015
31/08/2016
1400000000296
KLINIK PADJAJARAN
SUKANAGARA
PER/18/TC/1220
15
RS.TRAUMA
CENTRE
29/12/2015
31/08/2016
1400000000313
531719
PER/19/TC/1220
15
RS.TRAUMA
CENTRE
28/12/2015
31/08/2016
1500000001945
KLINIK RHAGASINDO
211068
PER/13/TC/0920
15
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
1400000000245
KLINIK SUKALARANG
MEDICAL SERVICE
JL SUKABUMI-CIANJUR KP MANGLID RT
03/02 DS CIMANGKOK SUKALARANG
260227
PER/11/TC/0820
15
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
10
1500000000371
PKM BAROS
DS BAROS
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
11
1500000000369
PKM BENTENG
JL BENTENG KIDUL
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
12
1500000000156
PKM CIBADAK
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
MA11222I
43111
DR NASOKA RAMLI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
153 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000360
JL CIBEUREUM HILIR
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
14
1500000000157
PKM CICANTAYAN
JL KH DAMANHURI KM 2 KEC
CICANTAYAN
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
15
1500000000159
PKM CICURUG
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
16
1500000000160
PKM CIDAHU
JL RAYA CIDAHU KM 7
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
17
1500000000152
PKM CIKEMBAR
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
18
1500000000362
PKM CIKUNDUL
JL PROKLAMASI
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
19
1500000000155
PKM CIPARI
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
20
1500000000372
PKM CIPELANG
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
21
1500000000368
JL OTTO ISKANDARDINATA
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
22
1500000000162
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
23
1500000000161
PKM KADUDAMPIT
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
24
1500000000361
JL MERBABU NO 14 GN PUYUH
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
154 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1500000000158
PKM KARAWANG
JL SELABINTANA KM 5
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
26
1500000000370
PKM LEMBURSITU
JL. LEMBURSITU
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
27
1500000000367
PKM LIMUSNUNGGAL
JL PELDA SURYANTA
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
28
1500000000365
PKM NANGGELENG
JL PELDA SUYATNA
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
29
1500000000364
PKM PABUARAN
JL PABUARAN
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
30
1500000000163
PKM PARAKANSALAK
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
31
1500000000149
PKM PARUNGKUDA
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
32
1500000000150
PKM SEKARWANGI
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
33
1500000000358
PKM SELABATU
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
34
1500000000373
PKM SUKABUMI
JL RAYA CIAUL
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
35
1500000000363
PKM SUKAKARYA
JL TEGAL WANGI
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
36
1500000000154
PKM SUKALARANG
PER/02/TC/0220
15
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
155 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/03/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
224128
PER/02/TC/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
224128
PER/14/TC/12/20
15
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
RS BHAKTI MEDICARE
731555
SUPRIADI SETIAWAN
PER/06/TC/0520
15
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000237
RS HERMINA SUKABUMI
6252525
DR HASMORO, MHA, MM
PER/07/TC/0620
15
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
42
1500000000359
RS. AL MULK
JL LEMBURSITU
PER/04/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
43
1400000000522
PER/11/TC/1220
14
RS.TRAUMA
CENTRE
01/01/2015
31/12/2016
44
1400000000287
RSUD CIANJUR
PER/16/TC/1220
15
RS.TRAUMA
CENTRE
29/12/2015
31/08/2016
45
1400000000671
RSUD CIMACAN
512465
PER/15/TC/1220
15
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
46
1400000000671
RSUD CIMACAN
512465
PER/13/TC/1220
14
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
47
1500000000060
PER/20/TC/1220
15
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
48
1500000000060
PER/01/TC/0120
15
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
37
1500000000366
PKM TIPAR
JL PEGADAIAN NO 1
38
1500000000059
RS BETHA MEDIKA
39
1500000000059
RS BETHA MEDIKA
40
1400000000196
41
MA11222I
229207
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
156 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
49
1500000000515
RSUD R. SYAMSUDIN SH
PER/05/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
50
1500000000428
RUMKITBAN 03.08.01
PANGRANGO
JL. PGRI NO 8
PER/05/TC/0420
15
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001229
KLINIK PADJADJARAN
KARANGPAWITAN
0435877
PT RS PADJADJARAN
PER/02/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
1500000000772
KLINIK PADJADJARAN
LEUWIGOONG
0435877
PT RS PADJADJARAN
PER/03/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
1500000000806
KLINIK PRATAMA
PADJADJARAN WANARAJA
0435877
PT RS PADJADJARAN
PER/05/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
10223001
PUSKESMAS JAMANIS
PER/23/062015
RS.TRAUMA
CENTRE
01/06/2015
30/05/2016
1400000000593
PER/68/122015
RS.TRAUMA
CENTRE
09/02/2016
31/12/2016
03800005
PER/55/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10241501
UPTD PUSKESMAS
BAYONGBONG
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
331808
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
157 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001218
UPTD PUSKESMAS
BOJONGGAMBIR
PER/20/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10242501
UPTD PUSKESMAS
BUNGBULANG
PER/35/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
10295301
UPTD PUSKESMAS
BUNGURSARI
PER/51/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
10221001
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
12
10241201
PER/27/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
13
10290801
UPTD PUSKESMAS
CIBEUREUM
PER/46/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
10221501
UPTD PUSKESMAS
CIGALONTANG
PER/62/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
15
10293701
UPTD PUSKESMAS
CIGEUREUNG
PER/48/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
10290301
UPTD PUSKESMAS
CIHIDEUNG
PER/42/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
17
10241801
UPTD PUSKESMAS
CIKAJANG
PER/32/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
18
10222501
UPTD PUSKESMAS
CIKATOMAS
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
19
10241601
PER/30/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
158 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
20
10294401
UPTD PUSKESMAS
CILEMBANG
21
10220901
22
10220601
UPTD PUSKESMAS
CISAYONG
23
10242701
24
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/49/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/58/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10241701
UPTD PUSKESMAS
CISURUPAN
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
25
10240503
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
26
10223901
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
27
10290401
UPTD PUSKESMAS
INDIHIANG
PER/43/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
28
1500000001069
PER/07/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
29
10224701
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
30
10223101
UPTD PUSKESMAS
KADIPATEN
PER/09/06/2015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
31
10293601
UPTD PUSKESMAS
KAHURIPAN
PER/38/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
380562
420560
957815
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
159 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
32
10290502
PER/45/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
33
10220902
UPTD PUSKESMAS
KARANGJAYA
PER/59/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
34
10222101
UPTD PUSKESMAS
KARANGNUNGGAL
PER/21/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
35
10290501
PER/44/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
36
10240701
PER/25/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
37
10221401
UPTD PUSKESMAS
LEUWISARI
PER/61/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
38
10240901
UPTD PUSKESMAS
LIMBANGAN
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
39
10293501
UPTD PUSKESMAS
MANGKUBUMI
PER/47/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
40
10220701
UPTD PUSKESMAS
MANONJAYA
PER/15/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
41
10221201
UPTD PUSKESMAS
PAGEURAGEUNG
PER/60/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
42
1500000001230
UPTD PUSKESMAS
PAMEUNGPEUK
PER/34/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
43
10295001
UPTD PUSKESMAS
PANGLAYUNGAN
PER/50/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
160 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
44
03800001
UPTD PUSKESMAS
PARAKAN NYASAG
PER/52/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
45
10294501
UPTD PUSKESMAS
PURBARATU
PER/39/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
46
10221101
UPTD PUSKESMAS
RAJAPOLAH
PER/17/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
47
1500000001225
PER/63/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
48
1500000001068
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
49
03800004
UPTD PUSKESMAS
SAMBONGPARI
PER/54/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
50
03800103
UPTD PUSKESMAS
SANGKALI
PER/57/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
51
10223301
UPTD PUSKESMAS
SARIWANGI
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
52
10241901
UPTD PUSKESMAS
SINGAJAYA
PER/33/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
53
10221301
UPTD PUSKESMAS
SINGAPARNA
PER/08/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
54
03800003
UPTD PUSKESMAS
SUKALAKSANA
PER/53/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
55
1500000001217
UPTD PUSKESMAS
SUKARAJA
PER/19/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
543414
545773
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
161 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
56
10292901
UPTD PUSKESMAS
TAMANSARI
PER/37/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
57
1500000001227
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
58
10240401
UPTD PUSKESMAS
TAROGONG
PER/24/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
59
1500000001216
PER/40/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
60
1500000001216
PER/40/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
61
10221302
UPTD PUSKESMAS
TINEUWATI
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
62
0380012
PER/56/06/2015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
63
1500000001226
PER/56/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
64
10221701
PER/15/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
65
10290201
PER/41/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
66
10241301
UPTS PUSKESMAS
MALANGBONG
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
162 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000758
KLINIK ANGKASA
TNI AU
PER/15/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001872
KLINIK ANNISA I
HJ NURUL HIDAYATI
PER/14/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000529
310524
PER/15/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000000528
270830
PER/16/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000000530
KLINIK AQMA
PURWAKARTA
200377
PER/17/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000000542
JL COMPRENG NO 25 PUSAKAJAYA
SUBANG
540261
PER/18/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000000696
KLINIK CAMPAKA
212451
PER/12/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000769
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000391
KLINIK MIRACLE
351377
DR SUSANTO
ONGKOWIDJAJA
PER/19/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
10
1500000000694
KLINIK MUNJUL
212451
PER/11/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1500000000695
212451
PER/13/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
12
1500000001208
DR PEPEN SOFYAN
EFENDI
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
163 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000001020
KLINIK RADIATIE
DR PEPEN SOFIAN
EFENDI
PER/ 21/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
1500000001022
KLINIK WALUYA
JL . RE MARTADINATA NO 60
DR . PEPEN SOFIAN
EFENDI
PER/ 20 / 052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
15
1500000001021
DR PEPEN SOFIAN
EFENDI
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1400000000326
PUSKESMAS CIASEM
081320777
941
PER/09/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
17
1400000000328
PUSKESMAS CIBOGO
081218499
93
PER/10/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
18
1400000000329
PUSKESMAS CIPEUNDEUY
SUBANG
DINAS KESEHATAN
PER/11/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
19
1400000000330
PUSKESMAS PABUARAN
081320284
083
DINAS KESEHATAN
PER/12/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
20
PER/ 09/022015
PUSKESMAS RAWALELE
082216333
567
PER/09/022015
RS.TRAUMA
CENTRE
01/02/2015
01/01/2016
21
1500000000404
RS BHAKTI HUSADA II
PURWAKARTA
8225344
PER/11/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
22
1500000000759
RS PANGKALAN TNI AU
SURYADARMA
TNI AU SURYADARMA
PER/16/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
23
1300000000035
RS. MH THAMRIN
PURWAKARTA
8222222
DR.H. KEMAL
MUHAMAD,
MMR.,M.KES,AIFO
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
1300000000035
RS. MH THAMRIN
PURWAKARTA
8222222
DR.H. KEMAL
MUHAMAD,
MMR.,M.KES,AIFO
PER/01/012016
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
164 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
25
1400000000434
JL VETERAN NO 39
26
1400000000441
JL BIGJEN KATAMSO NO 37
27
1500000001876
202136
28
1500000000405
SILOAM HOSPITALS
PURWAKARTA
JL. BUNGURSARI NO 1
219168
29
1400000000401
YAYASAN AQMA
JL STASIUN NO 93 CIKAMPEK
KANTOR CABANG
NO
KODE PROVIDER
PIMPINAN
DINAS KESEHATAN
KABUPATEN SUBANG
TIPE IKS
AWAL IKS
AKHIR IKS
PER/20/102015
RS.TRAUMA
CENTRE
21/01/2016
31/10/2016
PER/14/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
PER/18/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/ 10/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/13/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001517
340202
DR H. SUNUHARDO EP,
M.KES
PER/11/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
1500000001517
340202
DR H. SUNUHARDO EP,
M.KES
PER/35/062015
RS.TRAUMA
CENTRE
19/06/2015
31/12/2015
1500000000409
8862936
MUHAMMAD SAFI'I
MA'ARIF ,SE
PER/17/032015
RS.TRAUMA
CENTRE
31/03/2015
31/12/2015
1500000000409
8862936
MUHAMMAD SAFI'I
MA'ARIF ,SE
PER/15/2016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
165 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000847
641968
SUDIARTO (08121918055)
PER/30/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
1500000000847
641968
SUDIARTO (08121918055)
PER/16/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
7-1372189411
MARANTINO LUMMUSA
PER/24/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
1500000000846
KLINIK GEMPOL
02678453903
SUDIARTO (08121918055)
PER/32/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
1500000000846
KLINIK GEMPOL
02678453903
SUDIARTO (08121918055)
PER/17/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
10
1500000001515
310101
PER/33/062015
RS.TRAUMA
CENTRE
19/06/2015
31/12/2015
11
1500000001515
310101
PER/12/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
12
1500000001516
DR H DYAH PERMATA
SURYARINI M.KES
PER/34/062015
RS.TRAUMA
CENTRE
19/06/2015
31/12/2015
13
1500000001516
DR H DYAH PERMATA
SURYARINI M.KES
PER/13/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
14
1500000001518
435527
PER/14/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
15
1500000001518
435527
PER/36/062015
RS.TRAUMA
CENTRE
19/06/2015
31/12/2015
16
1500000000843
483749
SUDIARTO (08121918055)
PER/31/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
MA11222I
41371
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
166 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1500000000843
483749
SUDIARTO (08121918055)
PER/18/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
18
1500000000840
433930
SUDIARTO
PER/28/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
19
01019
433930
DR. YUNITA
PUSPITASARI
PER/19/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
20
1500000000463
KLINIK NAYAKA
418430
PENDI SUPENSI
PER/20/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
21
1500000000463
KLINIK NAYAKA
418430
PENDI SUPENSI
PER/19/032015
RS.TRAUMA
CENTRE
31/03/2015
31/12/2015
22
1500000000848
433653
SUDIARTO (08121918055)
PER/21/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
23
1500000000848
433653
SUDIARTO (08121918055)
PER/29/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
24
1500000001948
41311
085624943
888
YAYAT SALEH
PER/25/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
25
1500000001948
41311
085624943
888
YAYAT SALEH
PER/44/092015
RS.TRAUMA
CENTRE
21/09/2015
31/12/2015
26
1500000000407
KLINIK YAKESTI
432416
MUHAMMAD SAFEI'I
MA'ARIF
PER/16/032015
RS.TRAUMA
CENTRE
31/03/2015
31/12/2015
27
1500000000407
KLINIK YAKESTI
432416
MUHAMMAD SAFEI'I
MA'ARIF
PER/22/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
28
1500000001714
KLINIK YASMIN
SAFRINA DEWI
PER/38/062015
RS.TRAUMA
CENTRE
29/06/2015
31/12/2015
MA11222I
41311
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
167 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
SAFRINA DEWI
PER/23/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
8452555
NY ANGELIAQUE
ARYANTO
PER/27/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
8452555
NY ANGELIAQUE
ARYANTO
PER/09/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
41311
026740181
8
DR WHISNU SANTOSO
PER/01/012016
RS.TRAUMA
CENTRE
06/01/2016
31/12/2016
41312
414245
PER/26/052015
RS.TRAUMA
CENTRE
18/05/2015
31/12/2015
RS CITO
41312
PER/03/012016
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
1400000000368
437507
ADE RELAWATI
PER/05/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
36
1400000000368
437507
ADE RELAWATI
PER/22/04/2015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
37
1500000001708
41311
403073
PT DELIMA SISMA
MEDIKA
PER/37/062015
RS.TRAUMA
CENTRE
29/06/2015
31/12/2015
38
1500000001708
41311
403073
PT DELIMA SISMA
MEDIKA
PER/04/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
39
1400000000349
RS ISLAM KARAWANG
PER/06/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
40
1400000000349
RS ISLAM KARAWANG
PER/21/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
29
1500000001714
KLINIK YASMIN
30
1500000000849
LIRA MEDIKA
31
1500000000849
LIRA MEDIKA
32
7-1272337870
RS BAYU KARTA
33
1500000000814
RS CITO
34
7-1122449393
35
MA11222I
41311
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
168 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
41
1500000000408
RS IZZA
8386830
PER/07/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
42
1500000000408
RS IZZA
8386830
PER/15/032015
RS.TRAUMA
CENTRE
31/03/2015
31/12/2015
43
1400000000348
RS KARYA HUSADA
PER/20/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
44
1400000000348
RS KARYA HUSADA
PER/08/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
45
1400000000347
DR AKID
PER/23/04/2015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
46
1400000000347
DR AKID
PER/10/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
47
7-140398203
RS TC HERMINA GRAND
WISATA
DR. HASMORO
PER/55/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2016
48
06823
JL WIRASABA NO 54 JOHAR
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
49
7-1277095197
PER/02/012015
RS.TRAUMA
CENTRE
05/01/2016
30/06/2016
KANTOR CABANG
MA11222I
17510
82651212
403073
41314
H SAEPUDIN
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
169 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
1500000001616
1500000000232
6640384
1500000000679
085102712
227
1500000000682
085320241
143
1500000000683
082318663
331
1500000000678
085100792
646
1500000001615
KLINIK PADJADJARAN
RENDE
1500000000684
1500000000685
10
1500000001930
KLINIK PRATAMA
RAHARDJA
11
1500000000233
12
1500000000234
MA11222I
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PER/69/062015
RS.TRAUMA
CENTRE
01/07/2015
01/07/2016
PT NAYAKA ERA
HUSADA CABANG
CIMAHI
PER/02/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
PT NAYAKA ERA
HUSADA CABANG
CIMAHI
PER/59/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/61/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/62/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/60/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
DR WENDY FREELY
NUGRAHA
PER/67/062015
RS.TRAUMA
CENTRE
01/07/2015
01/07/2016
6806575
ANNEU FEURYTA
PER/63/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
6123955
ANNEU FEURYTA
PER/64/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
081321355
812
ENDANG HARTATI
AM.KEP
PER/72/082015
RS.TRAUMA
CENTRE
03/08/2015
30/06/2016
6674146
PER/03/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
6806125
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
40391
PT NAYAKA ERA
HUSADA CABANG
CIMAHI
PT NAYAKA ERA
HUSADA CABANG
CIMAHIA CABANG
CIMAHI
PT NAYAKA ERA
HUSADA CABANG
CIMAHI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
170 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1100000000027
RS DUSTIRA
6633967
PER/70/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
14
1400000000224
RSU AVISENA
6000830
PER/71/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
15
1400000000225
6652025
PER/68/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000508
BALAI PENGOBATAN
ELTIGIP
082116018
157
ENDANG WALSUM
PER/21/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
1500000000481
KLINIK AFIATI
BOJONGSOANG
95547889
PER/08/032015
FFS
01/03/2015
31/12/2015
1500000000491
KLINIK AFIATI
CICALENGKA
91192060
DR.AMETA PRIMASARI,
DRG, MKES, MDSC.
PER/09/032015
FFS
01/03/2015
31/12/2015
1500000000490
5892159
PER/10/032015
FFS
01/03/2015
31/12/2015
1500000000499
85963355
DR HERVI NURYANIA
MEGA REZA
PER/15/032015
FFS
01/03/2015
31/12/2015
1500000000485
081395373
337
PER/19/032015
FFS
01/03/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
171 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000484
85873559
BAMBANG TRIYONO
PER/18/032015
FFS
01/03/2015
31/12/2015
1500000000521
081320009
434
PEMERINTAH PROPINSI
PER/14/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
1500000000506
KLINIK MARLINA
085722699
969
PER/11/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
10
1500000000482
7537511
LULU FOTUANA
PER/12/032015
FFS
01/03/2015
31/12/2015
11
1500000000483
7537511
LULU FOTUANA
PER/13/032015
FFS
01/03/2015
31/12/2015
12
1500000000489
085106398
668
PER/04/032015
FFS
01/03/2015
31/12/2015
13
1500000000488
082318663
334
PER/05/032015
FFS
01/03/2015
31/12/2015
14
1500000000487
082318663
331
PER/06/032015
REIMBURSE
02/03/2015
31/12/2015
15
1500000000487
082318663
331
PER/06/032015
FFS
02/03/2015
31/12/2015
16
1500000000511
KLINIK PADJADJARAN
083820435
877
PER/22/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
17
1500000000486
85963355
PER/16/032015
FFS
01/03/2015
31/12/2015
18
1500000000492
081206052
93
DR. RATNA
SARIHARYANTI
PER/17/032015
FFS
01/03/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
172 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
19
1500000000510
5950916
PER/07/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
20
0900000000038
7781630
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
21
1300000000042
RS BHAYANGKARA
BANDUNG (TRAUMA
CENTER)
5229544
POLDA JABAR
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1500000000135
RSU PAKUWON
210931
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
23
1500000000135
RSU PAKUWON
210931
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
1500000000505
RSUD KABUPATEN
SUMEDANG
7217744
PER/20/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
25
1500000001175
5207963
DR.H GUNTUR
ALAMSYAH, MARS
PER/23/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1400000000556
CIPUTRA HOSPITAL
1500000001507
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
59405555
TIPE IKS
AWAL IKS
AKHIR IKS
CIPUTRA
PKS/26/122015
RS.TRAUMA
CENTRE
30/12/2015
31/12/2016
DR.A GHOFIR
PER/ PKS/ 14 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
173 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001507
DR.A GHOFIR
PKS/31/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000001506
PER/ PKS/ 16 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001506
PKS/33/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000001513
DR SABRI
PKS/32/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000001513
DR SABRI
PER/ PKS/ 15 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001314
KLINIK MILENIA
SEJAHTERA 1 TIGARAKSA
29006869
PER / TC / 11 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001314
KLINIK MILENIA
SEJAHTERA 1 TIGARAKSA
29006869
PKS/28/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
10
1500000001309
KLINIK MILENIA
SEJAHTERA 2 BALARAJA
29015571
PKS/29/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
11
1500000001309
KLINIK MILENIA
SEJAHTERA 2 BALARAJA
29015571
PER / TC / 12
/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001512
PKS/30/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
13
1500000001512
PKS/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
14
1500000001508
MUSAFAH
PER/ PKS/ 17 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
174 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
15
1500000001508
MUSAFAH
PKS/34/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
16
1500000001510
MUSAFAH
PER/ PKS/ 18 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
17
1500000001510
MUSAFAH
PKS/35/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
18
1500000001504
PKS/36/122015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
19
1500000001504
PER/ PKS/ 19 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
20
1500000001295
PER/TC/10/0620
15
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
21
1400000000665
RSUD BALARAJA
26327666
KAB. TANGERANG
PKS/27/122015
RS.TRAUMA
CENTRE
30/12/2015
31/12/2015
22
1500000000734
5962790
DR.NINDYAKUSUMA
KORATIWIDA,MARS
PKS / 05 /
052015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
KANTOR CABANG
NO
KODE PROVIDER
1400000000407
MA11222I
NAMA PROVIDER
KLINIK ANNISA II
ALAMAT
JL. RAYA CIBARUSAH RUKO POIN, NO.31-R
,DESA SUKARESMI, KEC. CIKARANG
SELATAN, KABUPATEN BEKASI
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
8976189
PT ANNISA MITRA
HUSADA
PER/49/102015
TIPE IKS
RS.TRAUMA
CENTRE
AWAL IKS
01/10/2015
AKHIR IKS
30/09/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
175 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000406
KLINIK ANNISA IV
89954434
PT ANNISA MITRA
HUSADA
PER/50/2015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000001951
KLINIK ANNISAIII
8976189
PT ANNISA MITRA
HUSADA
PER/42/092015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000001324
KLINIK AS-SHOFWAN
89140813
PT AS-SHOFWAN
TUNGGAL MANDIRI
NOMOR:PER /
20 / 062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001323
KLINIK AS-SYIFA
89100792
CV. AS-SYIFA
ANUGERAH RAYA
PER/22/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001952
8937941
PT BERKAT MELIMPAH
PRATAMA
PER/44/092015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000000180
89111103
PER/06/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
1500000001529
89111103
PER/24/062015
RS.TRAUMA
CENTRE
01/06/2015
31/01/2016
1500000001530
89111103
DR LIA NURLAELA
PER/25/062015
RS.TRAUMA
CENTRE
01/06/2015
31/01/2016
10
1400000000388
KLINIK CIKARANG
MEDICAL CENTER
8934371
RS AWAL BROS
HOSPITAL GROUP
PER/51/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
11
7-1199819163
DR HERTI E.SILALAHI
PER/54/122015
RS.TRAUMA
CENTRE
29/12/2015
30/11/2016
12
1400000000549
89836243
PER/54/122015
RS.TRAUMA
CENTRE
05/01/2016
30/11/2016
13
1400000000247
KLINIK INTRIMED
89882355
PT PERSADA SARI
MEDIKA
PER/33/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
17530
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
176 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
14
1500000001977
17211
89104266
SRI HANDAYANI
PER/53/1015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
15
1500000001977
17211
89104266
SRI HANDAYANI
PER/53/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
16
1500000001977
17211
89104266
SRI HANDAYANI
PER/53/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
17
7-1254255963
17530
DR KETTLER SIAHAAN,
MBA
PER/58/122015
RS.TRAUMA
CENTRE
04/01/2016
04/11/2016
18
1400000000283
89835510
PT NAYAKA ERA
HUSADA
PER/34/082015
RS.TRAUMA
CENTRE
01/08/2015
31/07/2016
19
1400000000220
89677085
NAYAKA HUSADA 03
PER/40/082015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
20
1500000000479
89950242
PT NAYAKA ERA
HUSADA
PER/14/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
21
1400000000258
KLINIK PRODIA
OCCUPATIONAL HEALTH
CENTRE
29083408
PT PRODIA OHI
INTERNASIONAL
PER/35/082015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
22
1400000000389
8971932
DR.H.MULYANA SYARIF
PANIJA
PER/45/092015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
23
1500000001528
8971932
MULYANA SYARIP
PANIJA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/10/2015
24
1500000001528
8971932
MULYANA SYARIP
PANIJA
PER/46/102015
RS.TRAUMA
CENTRE
01/11/2015
31/10/2016
25
1500000001527
89950333
H.MULYANA SYARIP
PANIJA
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
30/09/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
177 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
26
1500000001527
27
1500000001856
KLINIK SETIA 3
28
1500000000193
29
7-1251921754
RS AMANDA
30
1400000000004
RS AMANDA CIKARANG
31
7-1432249443
RS ANNISA CIKARANG
32
1500000001495
RS AS-SHOFWAN
33
1400000000055
RS BHAKTI HUSADA
34
7-1254255965
RS DR SANDER.B
35
1500000001950
RS HARAPAN KELUARGA
36
7-1250333673
RS HOSANA LIPPO
CIKARANG
37
1400000000003
RS HOSANA MEDICA
CIKARANG BARU
MA11222I
KODE
POS
17330
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
89950333
H.MULYANA SYARIP
PANIJA
PER/46/092015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
8971240
PER/30/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
70604934
HERI YULIANSYA, SE
PER/08/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
DR.HAMIDAH, M.KES
PER/60/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
DR HAMIDAH, M.KES
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
DR.NOOR ARIDA
SOFIANA, MBA
PER/55/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
89141890
PT AS-SHOFWAN
TUNGGAL MANDIRI
PER / 19 /
062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
89110896
PT HUSADA
PURWAKARTA
PER/36/082015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
DR. HASAN
PER/59/122015
RS.TRAUMA
CENTRE
05/01/2016
30/11/2016
PT HARAPAN
INTERNASIONAL
PER/41/092015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
JOHANNES POSO
PER/56/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
JOHANES POSO
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
17530
8971643
17530
17340
89840745
17530
29620630
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
178 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
38
1200000000013
8972472
JOHANES POSO
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
39
1500000000495
RS MEDIROSSA
89833216
PT MEDIROSSA MITRA
INSANI
PER/15/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
40
1500000001671
RS MEDIROSSA 2
CIBARUSAH
89955555
H.OMIN BASUNI SH
RS MEDIROSSA
2 CIBARUSAH
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
41
1500000001378
RS MITRA MEDIKA
JL RAYA JATIWANGI-CIKEDOKAN,
CIKARANG BARAT,KAB.BEKASI
98213879
PT MUTIARA ADHI
MEDIKA
PER/21/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
42
1500000001857
RS RIDHOKA SALMA
89116527
PT RIDHOKA SALMA
PER/31/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
43
1400000000387
RS SENTRA MEDIKA
8904160
PER / 48 /102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
44
1500000001575
RS SETIA
8971240
PER/28/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
45
1500000000844
RS SILOAM HOSPITALS
LIPPOCIKARANG
29636900
SILOAM HOSPITALS
PER/18/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
46
1100000000024
8904165
DR. ISMAIL
ALMUCHTARO MPH
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
47
1500000000471
82611565
PER/12/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
48
1500000000472
89161339
DR.MOHAMMAD NATSIR
PER/13/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
49
1300000000022
89905588
PER/16/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
17330
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
179 / 322
09-02-2016
18:49:59
NO
50
KODE PROVIDER
1500000001374
KANTOR CABANG
NO
NAMA PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
JL.KH.FUDHOLI.NO.78 CIKARANG,BEKASI
IKS
TELEPON
PIMPINAN
NO IKS
8902210
DR ULAM FRIDALAM
PER/23/062015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/07/2015
AKHIR IKS
30/06/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000873
KLINIK ALBAR
40225
085863333
599
YAYASAN LESTARI
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000873
KLINIK ALBAR
40225
085863333
599
YAYASAN LESTARI
PER/14/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000252
40241
5232291
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000252
40241
5232291
PER/19/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1500000001810
KLINIK BHAYANGKARA
HUSADA POLRES BANDUNG
40911
85871980
POLRES BANDUNG
PER/17/062015
RS.TRAUMA
CENTRE
22/06/2015
31/12/2015
1500000001810
KLINIK BHAYANGKARA
HUSADA POLRES BANDUNG
40911
85871980
POLRES BANDUNG
PER/16/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001538
KLINIK INSANIYAH
MEDICAL CENTRE
JL TERUSAN AL FATHU KM 17 RT 05 RW 04
DESA PAMEKARAN SOREANG
40911
85874343
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001538
KLINIK INSANIYAH
MEDICAL CENTRE
JL TERUSAN AL FATHU KM 17 RT 05 RW 04
DESA PAMEKARAN SOREANG
40911
85874343
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
180 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001541
KLINIK KATAPANG
40921
21175677
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
10
1500000001541
KLINIK KATAPANG
40921
21175677
PER/18/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1500000001537
40182
6037679
CV LUHUR MEDICA
CENTRE
PER/13/2015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001537
40182
6037679
CV LUHUR MEDICA
CENTRE
PER/19/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1400000000251
40921
61804614
PER/08/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
14
1400000000251
40921
61804614
PER/04/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
15
1400000000251
40921
61804614
PER/04/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
16
1500000000871
40377
5944144
DR HJ ROSIDAH AGUS
PER/11/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000000871
40377
5944144
DR HJ ROSIDAH AGUS
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
18
1500000000911
KLINIK RATNASARI 2
40973
5927794
APENG HIDAYAT
PER/07/052014
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
19
1500000000911
KLINIK RATNASARI 2
40973
5927794
APENG HIDAYAT
PER/13/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
20
1500000000872
40921
5897000
PER/10/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
181 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
21
1500000000872
40921
5897000
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
22
1500000000882
40378
081320605
293
APENG HIDAYAT
PER/05/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
23
1500000000882
40378
081320605
293
APENG HIDAYAT
PER/12/2016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
24
1500000001330
40238
5204139
DR RUKHIYAT SYAHIDIN
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
25
1500000001330
40238
5204139
DR RUKHIYAT SYAHIDIN
PER/07/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1500000001709
40253
5201501
PER/15/012016
RS.TRAUMA
CENTRE
01/01/2016
31/01/2016
27
1500000001709
40253
5201501
PER/18/062015
RS.TRAUMA
CENTRE
22/06/2015
31/12/2015
28
1400000000080
JL KIASTRAMANGGALA - BALEENDAH
40258
5940872
PER/03/032015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
29
1400000000080
JL KIASTRAMANGGALA - BALEENDAH
40258
5940872
PER/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
30
1100000000025
40241
5201051
YAYASAN BRS GK
PASUNDAN
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
31
1100000000025
40241
5201051
YAYASAN BRS GK
PASUNDAN
PER/20/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
32
1400000000532
JL RAJAWALI NO 38 RT 03 RW 10 KEC
ANDIR
40181
6011913
YAYASAN KEMANUSIAN
PER/06/012016
RS.TRAUMA
CENTRE
30/12/2015
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
182 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
33
1500000001540
40911
5891355
PEMERINTAH DAERAH
KAB. BANDUNG
PER/15/052015
RS.TRAUMA
CENTRE
04/05/2015
31/12/2015
34
1500000001540
40911
5891355
PEMERINTAH DAERAH
KAB. BANDUNG
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
35
1500000001715
SANTOSA HOSPITAL
BANDUNG CENTRAL
JL KEBONJATI NO 38 BANDUNG
40181
4248555
PT SANBE PRAKARSA
HUSADA
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
36
1500000001715
SANTOSA HOSPITAL
BANDUNG CENTRAL
JL KEBONJATI NO 38 BANDUNG
40181
4248555
PT SANBE PRAKARSA
HUSADA
PER/012/062015
RS.TRAUMA
CENTRE
15/06/2015
31/12/2015
37
1500000001388
SANTOSA HOSPITAL
BANDUNG KOPO
40221
54280555
PT SANBE PRAKARSA
HUSADA
PER/11/062015
RS.TRAUMA
CENTRE
15/06/2015
31/12/2015
38
1500000001388
SANTOSA HOSPITAL
BANDUNG KOPO
40221
54280555
PT SANBE PRAKARSA
HUSADA
PER/03/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001174
KLINIK ANGGI
KP CIBEBER DS KAHURIPAN
KLAPANUNGGAL
29219678
PER/23/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000001174
KLINIK ANGGI
KP CIBEBER DS KAHURIPAN
KLAPANUNGGAL
29219678
PER/23/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000001174
KLINIK ANGGI
KP CIBEBER DS KAHURIPAN
KLAPANUNGGAL
29219678
PER/04/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
183 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001514
8234492
PER/09/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
1500000001514
8234492
PER/28/062015
RS.TRAUMA
CENTRE
19/06/2015
31/12/2015
1500000001382
KLINIK DR IRMAN
YAYASAN SUMARNO
MEDIKA
PER/27/062015
RS.TRAUMA
CENTRE
16/06/2015
31/12/2015
1500000001382
KLINIK DR IRMAN
YAYASAN SUMARNO
MEDIKA
PER/08/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
1500000001207
DR MARZUKI
PER/05/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
1500000001207
DR MARZUKI
PER/24/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
10
7-1552354085
KLINIK EDELWEISS
16820
DR AFRIYANTI SANDHI
PER/12/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
11
1500000001990
KLINIK EDELWEISS
17435
84303724
DR AFRIYANTI SANDHI
PER/36/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
12
1500000001690
16820
29289475
DR HARUMITI
RAMIL,MKK
PER/11/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
13
1500000001690
16820
29289475
DR HARUMITI
RAMIL,MKK
PER/30/062015
RS.TRAUMA
CENTRE
26/06/2015
31/12/2015
14
1500000001687
KLINIK GRACIA
16820
PER/29/062015
RS.TRAUMA
CENTRE
26/06/2015
31/12/2015
15
1500000001687
KLINIK GRACIA
16820
PER/10/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
184 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1500000001331
KLINIK MH THAMRIN
MEKARSARI
8235052
DR RISKA ARISKA
YULIANTI
PER/06/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
17
1500000001331
KLINIK MH THAMRIN
MEKARSARI
8235052
DR RISKA ARISKA
YULIANTI
PER/25/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
18
1500000001383
KLINIK PKO
MUHAMMADIYAH
DR NUR CAHYANINGSIH
PER/07/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
19
1500000001383
KLINIK PKO
MUHAMMADIYAH
DR NUR CAHYANINGSIH
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
20
1500000001691
RS HERMINA MEKARSARI
16820
29232525
PER/01/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
21
1500000001691
RS HERMINA MEKARSARI
16820
29232525
PER/31/062015
RS.TRAUMA
CENTRE
26/06/2015
31/12/2015
22
1500000001927
RS PERMATA JONGGOL
16120
89931333
DR EVY FEBRINA
NURPENI, MARS
PER/03/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
23
1500000001927
RS PERMATA JONGGOL
16120
89931333
DR EVY FEBRINA
NURPENI, MARS
PER/32/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
24
1400000000327
RSTC MH THAMRIN
CILEUNGSI
JL RAYA NAROGONG KM 16
LIMUSNUNGGAL CILEUNGSI
8235052
DR ABDUL RADJAK
PER/35/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
25
1400000000327
RSTC MH THAMRIN
CILEUNGSI
JL RAYA NAROGONG KM 16
LIMUSNUNGGAL CILEUNGSI
8235052
DR ABDUL RADJAK
PER/02/012016
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
26
1500000000590
8230426
DRA FATIMAH
PER/21/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
185 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
1500000001870
1400000000281
KLINIK SAHABAT
1500000000649
RS DINDA
GALUH NO 2 JATIUWUNG
15133
1500000000649
RS DINDA
GALUH NO 2 JATIUWUNG
1500000000649
RS DINDA
1500000001827
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/27/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/5015
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PT DINDA MEDISTRA
PER/04/042016
RS.TRAUMA
CENTRE
26/01/2016
31/12/2016
15133
PT DINDA MEDISTRA
PER/04/012016
RS.TRAUMA
CENTRE
26/01/2016
31/12/2016
GALUH NO 2 JATIUWUNG
15133
PT DINDA MEDISTRA
PER/14/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
RS MELATI
15111
5523945
PT MELATI MEDIKA
SEJAHTERA
PER/28/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1100000000004
RSU AN NISA
5525564
DR EDIANSYAH, MARS
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1100000000004
RSU AN NISA
5525564
DR EDIANSYAH, MARS
PER/05/2016
RS.TRAUMA
CENTRE
27/01/2016
31/12/2016
1100000000005
5902226
DR E TRISNO SUSILO
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KANTOR CABANG
MA11222I
59300041
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
186 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
04047
ASY-SYIFA MEDICAL
CENTER
1500000001929
1500000001929
1500000001808
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
77883905
DR SOBARI
9878341
16411
77203062
DRG.SRI SULISWATI,MM
PER/15/072015
16411
77203062
DRG.SRI SULISWATI,MM
16413
7715039
1500000001808
16413
1500000001922
1500000001922
1500000001971
TIPE IKS
AWAL IKS
AKHIR IKS
22/09/2015
30/11/2015
FFS
01/08/2015
31/12/2015
PER/32/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
PER/31/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
7715039
PER/11/062015
FFS
01/07/2015
31/12/2015
16414
77219553
DR YANI HARYANI
PER/14/062015
FFS
01/07/2015
31/12/2015
16414
77219553
DR YANI HARYANI
PER/33/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
PRAKTEK DR MAS'UD
16421
7533780
DR. MAS'UD
PER/21/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
1500000001971
PRAKTEK DR MAS'UD
16421
7533780
DR. MAS'UD
PER/34/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
10
1400000000184
RS BHAKTI YUDHA
16511
7520082
THAMAS INVESTAMA
GUNA
PER/27/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
11
1400000000184
RS BHAKTI YUDHA
16511
7520082
THAMAS INVESTAMA
GUNA
PER/13/062015
RS.TRAUMA
CENTRE
05/06/2015
31/12/2015
12
1400000000183
RS BHAYANGKARA
SIKESJAS KORBRIMOB
87704691
DR TAUFIK
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
187 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1400000000183
RS BHAYANGKARA
SIKESJAS KORBRIMOB
87704691
DR TAUFIK
PER/18/062015
RS.TRAUMA
CENTRE
06/06/2015
31/12/2015
14
1400000000528
29671000
DR NENCY
PER/28/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
15
1500000001916
RS PERMATA DEPOK
16511
29669000
PT MUFIDAH MEDIKA
SAWANGAN
PER/10/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
16
1500000001916
RS PERMATA DEPOK
16511
29669000
PT MUFIDAH MEDIKA
SAWANGAN
PER/29/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
17
1500000001811
RS PERMATA DEPOK
16511
29669000
PT MUFIDAH MEDIKA
SAWANGAN
PER/10/062015
FFS
01/07/2015
31/12/2015
18
1400000000181
RS SENTRA MEDIKA
CISALAK
8743790
DR HERMAN
WIDYATOMO
PER/22/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
19
1400000000181
RS SENTRA MEDIKA
CISALAK
8743790
DR HERMAN
WIDYATOMO
PER/12/062015
RS.TRAUMA
CENTRE
06/06/2015
31/12/2015
20
1400000000182
RS SIMPANGAN DEPOK
D WARSITO
PER/24/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21
1400000000182
RS SIMPANGAN DEPOK
D WARSITO
PER/17/062015
RS.TRAUMA
CENTRE
10/06/2015
31/12/2015
22
1400000000180
RS TUGU IBU
8710870
H MARIS RINALDI
PER/23/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23
1400000000180
RS TUGU IBU
8710870
H MARIS RINALDI
PER/16/062015
RS.TRAUMA
CENTRE
10/06/2015
31/12/2015
24
1400000000285
7778899
DR PARAMITA
PER/25/122015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
188 / 322
09-02-2016
18:49:59
NO
25
KODE PROVIDER
1400000000285
KANTOR CABANG
NO
NAMA PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
7778899
DR PARAMITA
PER/19/072015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/08/2015
AKHIR IKS
31/12/2015
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
1500000001019
1500000000448
KLINIK AMIRA
1500000001463
1500000000621
5397314
1500000000323
KLINIK DR RANNY
75874222
1500000000441
1500000000440
1500000000442
MA11222I
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PROVINSI BANTEN
PER/19/052015
RS.TRAUMA
CENTRE
26/05/2015
31/05/2016
DR MURTININGRUM
PER/13/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
CV HOMY MEDICARE /
ALEX
PER/26/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER/015/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/07/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
DR AYAT RAHAYU
SP.RAD. MKES
PER/11/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
CIPUTAT TIMUR
DR AYAT RAHAYU
SP.RAD. M.KES
PER/12/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
CIPUTAT TIMUR
DR AYAT RAHAYU
SP.RAD MKES
PER/10/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
5383042
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
189 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7562156
PER/27/062015
RS.TRAUMA
CENTRE
22/06/2015
30/06/2016
15310
5386400
JAMES TAMPUBOLON
PER/31/072015
RS.TRAUMA
CENTRE
10/07/2015
09/07/2016
15310
5386400
JAMES TAMPUBOLON
PER/31/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
70947446
INDRA GUSMARDI
MARAN
PER/28/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
DR HJ SITI MURWANI
PER/08/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/23/062015
RS.TRAUMA
CENTRE
15/06/2015
30/06/2016
PT. BETHSAIDA
HOSPITAL
INTERNATIONAL
PER/14/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
7490018
PT.
BHINEKABAKTIHUSADA
PER/017/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
7456379
YAYASAN ICHSAN
PER/21/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
RS MEDIKA BSD
5373396
PT KHASANAH PUTERA
JAKARTA MEDIKA
PER/18/052015
RS.TRAUMA
CENTRE
01/06/2015
30/05/2016
7-1679975283
53125555
PT SARANA MEDITAMA
INTERNATIONAL
PER/01/012016
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
1400000000079
RS PERMATA PAMULANG
74704999
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000001521
10
1500000001875
11
1500000001875
12
1500000001613
KLINIK RAZZAAQ
13
1500000000443
KLINIK SURADITA
14
1500000001286
15
1500000000512
RS BETHSAIDA HOSPITAL
GADING SERPONG
16
1500000000709
17
1500000001210
RS IMC BINTARO
18
1500000001018
19
20
MA11222I
74711292
15325
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
190 / 322
09-02-2016
18:49:59
NO
21
KODE PROVIDER
1500000001209
KANTOR CABANG
NO
NAMA PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
7410808
PER/20/052015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/06/2015
AKHIR IKS
31/05/2016
NAMA PROVIDER
ALAMAT
1500000001801
BALAI PELATIHAN
TRANSMIGRASI DAN
PENYANDANG CACAT PROV
JATENG
1500000001753
1500000001800
1500000001720
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
6720566
M NATSIR NOOR
EFFENDY SH MSI
PER/17/062015
RS.TRAUMA
CENTRE
30/06/2015
29/06/2016
50263
91086136
KLINIK NAYAKA
HUSADA
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
JL BUKIT BARISAN C1 NO 11
50184
7628785
DR YETTI NASTUTI
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
50179
3548550
PER/14/4/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001719
PUSKESMAS BANDARHARJO
50175
3564787
PER/14/3/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001734
PUSKESMAS BANGETAYU
50115
6584353
DR SURYANTO SETYO
PRIHADI
PER/14/16/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001765
PUSKESMAS BOJA 01
51381
571025
DR LELY YULIANTY
PER/15/20/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001774
PUSKESMAS BOJA 2
JL DESA NGABEAN
51381
41001962
DR AGUS PRIBADI
PER/15/21/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
191 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001796
PUSKESMAS BRANGSONG 1
51371
3688944
DR WIWIEN YUNITA
INDRIYATI
PER/15/9/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000001767
PUSKESMAS BRANGSONG 2
51371
383107
DR SRIYATI
PER/15/10/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
7-1435412603
PUSKESMAS BRATI
58153
085290455
655
MURSIYATI, SKM
PER/22-1/112015
RS.TRAUMA
CENTRE
15/01/2016
31/12/2016
12
1500000001722
PUSKESMAS BUGANGAN
50126
3546061
PER/14/5/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
13
1500000001797
JL DR WAHIDIN NO 22 SEMARANG
8310515
PER/14/13/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
7-1435686266
PUSKESMAS GABUS I
58183
SOEPARNO, SKM
PER/22-2/112015
RS.TRAUMA
CENTRE
15/01/2016
31/12/2016
15
7-1435751247
PUSKESMAS GABUS II
58183
TOTOK EKO
SUBANDRIYO, SKM
PER/22-3/112015
RS.TRAUMA
CENTRE
15/01/2016
31/12/2016
16
1500000001730
PUSKESMAS GAYAMSARI
6744855
DR ASRI NUGRAHINI K
PER/14/12/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
17
1500000001781
PUSKESMAS GEMUH 1
JL PUSKESMAS NO 15 PAMRIHAN
388105
DR HJ SITI QOMARIYAH
PER/15/13/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
18
1500000001782
PUSKESMAS GEMUH 2
5704550
DR ANDI SETIAWAN
PER/15/14/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
19
1500000001733
PUSKESMAS GENUK
50117
8584188
DR RENI ERVINA
PER/14/30/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
20
7-1435773598
PUSKESMAS GEYER I
58172
00551107
PER/22-4/112015
RS.TRAUMA
CENTRE
15/01/2016
31/12/2016
MA11222I
51351
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
192 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
EDI SUCIPTO,
S.KEP.M.KES
PER/22-5/112015
RS.TRAUMA
CENTRE
15/01/2016
31/12/2016
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
PER/22-8/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
58164
029253332
6
PER/22-9/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
58164
029251353
488
DR. SUWINDI
PER/2210/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
6932140
DR YUNI ASTUTI
PER/14/22/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PUSKESMAS HALMAHERA
8414894
DR MUH HIDAYANTO
PER/14/27/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001731
PUSKESMAS KAGOK
JL TELOMOYO NO 3 SMG
8312573
PER/14/14/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
30
1500000001762
PUSKESMAS KALIWUNGU
JL RAYA KALIWUNGU NO 9A
382012
DR FATCHROYATI
SUSANA
PER/15/22/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
31
1500000001771
PUSKESMAS KALIWUNGU
SELATAN
92080045
DR HESTI
SULISTIYANINGSIH
PER/15/23/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
32
1500000001793
PUSKESMAS KANGKUNG 1
JL KH IBRAHIM NO 6 KANGKUNG
383181
DR ISTIAWATI
PER/15/25/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
21
7-1435791349
PUSKESMAS GEYER II
58172
22
7-1444349893
PUSKESMAS GODONG I
58162
23
7-1444478904
PUSKESMAS GODONG II
58162
24
7-1444574355
PUSKESMAS GROBOGAN
58152
25
7-1444762696
PUSKESMAS GUBUG I
26
7-1444853077
PUSKESMAS GUBUG II
27
1500000001743
PUSKESMAS GUNUNGPATI
28
1500000001721
29
MA11222I
50111
51353
029265932
2
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
193 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
33
1500000001794
PUSKESMAS KANGKUNG 2
51353
5703134
DR UMIYATI
PER/15/26/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
34
1500000001725
50144
7606065
DR SITI MASFUFAH
MKES
PER/14/7/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
35
1500000001723
50122
3540035
DR WAHYUDI
PER/14/28/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
36
1500000001746
PUSKESMAS KARANG
MALANG
JL RM SOEBAGIONO TJONDROKUSUMO
MIJEN SMG
70783410
DR ANASIH
RACHMAWATI
PER/14/35/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
37
1500000001751
PUSKESMAS
KARANGANYAR
50135
8662080
DR SRI MAHARSI
PER/14/26/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
38
7-1444951638
PUSKESMAS
KARANGRAYUNG I
58163
AGUNG DWI
SUJATMOKO, SKM
PER/2211/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
39
7-1445380831
PUSKESMAS
KARANGRAYUNG II
58163
PUJIYONO, SKM,M.KES
PER/2212/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
40
7-1445437092
PUSKESMAS KEDUNGJATI
58167
029265808
8
DR. HARDJOKO
PER/2213/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
41
1500000001737
PUSKESMAS
KEDUNGMUNDU
50273
6717053
TURI SETYOWATI
PER/14/18/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
42
1500000001758
PUSKESMAS KENDAL 01
51311
3843409
PER/15/29/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
43
1500000001769
PUSKESMAS KENDAL 2
51318
383309
DR SITI MUSRIAH
PER/15/30/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
44
7-1445504163
PUSKESMAS KLAMBU
58154
081575586
160
PER/2214/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
194 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
45
7-1445537804
PUSKESMAS KRADENAN I
58182
029276124
1
DR. YATINO
PER/2215/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
46
7-1445609485
PUSKESMAS KRADENAN II
58182
029276157
7
SUBANDI, SKM
PER/2216/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
47
1500000001728
PUSKESMAS KROBOKAN
JL ARIBUANA NO 1 SEMARANG
50141
7610084
PER/14/10/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
48
1500000001724
PUSKESMAS LAMPER
TENGAH
84444808
DR SULISTYOWATI
PER/14/6/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
49
1500000001726
PUSKESMAS LEBDOSARI
50145
7610207
PER/14/8/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
50
1500000001768
PUSKESMAS LIMBANGAN
JL RAYA LIMBANGAN NO 3
51383
3673283
DR SLAMET RIYANTO
PER/15/8/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
51
1500000001750
PUSKESMAS MANGKANG
50156
8660675
DR BUDI MULYANTO
PER/14/37/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
52
1500000001727
PUSKESMAS MANYARAN
50149
7601883
SUFARKAH SKM
PER/14/9/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
53
1500000001745
PUSKESMAS MIJEN
7711083
DR YETTI NASTUTI
PER/14/34/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
54
1500000001718
PUSKESMAS MIROTO
3552542
SUMARTOPO SKM
PER/14/2/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
55
1500000001749
PUSKESMAS NGALIYAN
7608795
DR WAHIDAH
NOFRIDALIA
PER/14/36/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
56
1500000001792
PUSKESMAS NGAMPEL
383084
PER/15/12/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
50134
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
195 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
57
7-1445738346
PUSKESMAS NGARINGAN
58193
081225177
040
PER/2217/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
58
1500000001729
PUSKESMAS NGEMPLAK
SIMONGAN
50148
7610212
PER/14/11/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
59
1500000001739
PUSKESMAS NGESREP
50262
7474113
DR AHNAF
PER/14/32/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
60
1500000001740
PUSKESMAS PADANGSARI
50261
7472460
DR JULIUS TJANDRA
PER/14/20/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
61
1500000001777
PUSKESMAS PAGERUYUNG
DS PUCAKWANGI PAGERUYUNG
51361
5790987
DR SULASIH
PER/15/4/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
62
1500000001752
PUSKESMAS PANDANARAN
JL PANDANARAN NO 79 SEMARANG
50144
8311470
DR ANTONIA S
PER/14/29/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
63
1500000001760
PUSKESMAS PATEAN
51364
451531
PER/15/5/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
64
1500000001764
PUSKESMAS PATEBON 02
51351
3686051
DR ISTIQOMAH TRI
HANDAYANI
PER/15/28/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
65
1500000001795
PUSKESMAS PATEBON 1
51351
5790390
DR ULIA HUDA
PER/15/27/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
66
1500000001732
PUSKESMAS PEGANDAN
50274
8445809
PER/14/15/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
67
1500000001761
PUSKESMAS PEGANDON
383705
DR NUR WIDYASTUTI
PER/15/11/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
68
7-1445782077
PUSKESMAS PENAWANGAN
I
029242710
70
PER/2218/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
MA11222I
58161
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
196 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
69
7-1445869188
PUSKESMAS PENAWANGAN
II
58161
70
1500000001776
PUSKESMAS PLANTUNGAN
JL RAYA NO 21 PLANTUNGAN DS
TIRTOMULYO
51362
71
1500000001763
72
1500000001717
PUSKESMAS PONCOL
73
1500000001742
74
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/2219/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
451714
DR BUDI MULYONO
PER/15/1/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
51352
383475
DR SRI INAYATI
PER/15/24/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
50132
3546053
DRG SUTANTI
PER/14/1/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
PUSKESMAS PUDAK
PAYUNG
50269
7462711
PER/14/21/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
7-1445943179
PUSKESMAS PULOKULON I
58181
081325129
862
PER/2220/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
75
7-1445969030
PUSKESMAS PULOKULON II
58181
PER/2221/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
76
7-1446062441
PUSKESMAS PURWODADI I
58111
029242154
1
PER/2222/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
77
7-1446286013
PUSKESMAS PURWODADI II
58111
029277014
14
DR. RINJANI
SURYANINGSIH, MA
PER/2223/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
78
1500000001748
PUSKESMAS PURWOYOSO
50263
7612927
PER/14/25/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
79
1500000001780
PUSKESMAS RINGINARUM
5701268
DR ENDAH PUSPITORINI
PER/15/15/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
80
1500000001738
PUSKESMAS ROWOSARI
7019382
PER/14/19/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
197 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
81
1500000001757
PUSKESMAS ROWOSARI 02
KENDAL
51311
641541
PER/15/19/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
82
1500000001779
PUSKESMAS ROWOSARI 1
51354
5792354
DR YUNI WIDIASTUTI
PER/15/18/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
83
1500000001744
PUSKESMAS SEKARAN
JL RAMBUTAN NO 44 SEKARAN
GUNUNGPATI SMG
70772838
DR LILIK FARIDAH
PER/14/23/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
84
1500000001773
PUSKESMAS SINGOROJO 1
JL NGAREANAK SINGOROJO
572328
PER/15/6/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
85
1500000001772
PUSKESMAS SINGOROJO 2
571928
DR DWI YULIAWATI
PER/15/7/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
86
1500000001741
PUSKESMAS SRONDOL
50263
7472852
DR NOEGROHO EDY
RIJANTO MKES
PER/14/33/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
87
1500000001759
PUSKESMAS SUKOREJO 01
JL BANARAN NO 4 SUKOREJO
51363
451314
DR MUKHAMMAD TOHA
PER/15/2/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
88
1500000001775
PUSKESMAS SUKOREJO 2
JL SUKOREJO NGADIWARNO
51363
452104
DR I MADE ASTAWA
PER/15/3/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
89
1500000001747
8661743
DRG SAKINAH
PER/14/24/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
90
7-1446397684
PUSKESMAS
TANGGUNGHARJO
58166
DR. KUSAINI
PER/2224/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
91
7-1446533475
PUSKESMAS
TAWANGHARJO
58191
DRG. RENDRA M
PER/2225/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
92
7-1446647286
PUSKESMAS TEGOWANU
58165
PER/2226/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
MA11222I
029251351
50
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
198 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
93
1500000001736
PUSKESMAS TLOGOSARI
KULON
50196
6717051
DR INDAH WIDIASTUTI
PER/14/31/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
94
1500000001735
PUSKESMAS TLOGOSARI
WETAN
50111
8713083
DR NURHAYATI MKES
PER/14/17/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
95
7-1446759157
PUSKESMAS TOROH I
58171
029255219
2
PER/2227/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
96
7-1446805408
PUSKESMAS TOROH II
58171
PER/2228/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
97
1500000001766
PUSKESMAS WELERI 02
51355
643245
PER/15/17/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
98
1500000001778
PUSKESMAS WELERI 1
JL TAMTAMA NO 3 WELERI
51355
641023
PER/15/16/06201
5
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
99
7-1446854619
PUSKESMAS WIROSARI I
58192
029276102
9
445/1722/2014
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
100
7-1446890010
PUSKESMAS WIROSARI II
58192
SUTRISNO, SKM
PER/2230/112015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
101
1400000000218
JL DR SOETOMO NO 17
3555944
PER/017/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
102
1400000000218
JL DR SOETOMO NO 17
3555944
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
103
7-953735513
RS COLUMBIA ASIA
SEMARANG
PT BELEFINA SARANA
MEDIKA
PER/28/122015
RS.TRAUMA
CENTRE
11/12/2015
30/11/2016
104
1500000000212
RS ISLAM KENDAL
PER/25/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
50131
641870
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
199 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
105
1500000000212
RS ISLAM KENDAL
641870
PER/022/022015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
106
1500000001046
RS MUHAMMADIYAH
GUBUG
533102
DR M ARIF RIDA
PER/09/052015
RS.TRAUMA
CENTRE
11/05/2015
10/05/2016
107
1500000000223
421087
DR SUNARIMA, M.KES
PER/024/022015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2016
108
1500000001404
RS PANTIWILASA DR CIPTO
SEMARANG
JL DR CIPTO NO 50 SEMARANG
3546040
YAKKUM
PER/11/062015
RS.TRAUMA
CENTRE
04/06/2015
03/06/2016
109
1400000000217
RS PELITA ANUGERAH
6725555
LIDIA MEGAWATI
PER/23/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
110
1400000000217
RS PELITA ANUGERAH
6725555
LIDIA MEGAWATI
PER/020/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
111
1500000000210
RS PERMATA BUNDA
422838
DR H UTOMO DS SPOG
PER/31/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
112
1400000000219
RS PERMATA MEDIKA
7625005
PER/24/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
113
1400000000219
RS PERMATA MEDIKA
7625005
PER/019/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
114
1500000000648
RS ROEMANI
MUHAMMADIYAH
SEMARANG
JL WONODRI 22 SEMARANG
8444623
PROF.DR.DR.H.RIFKI
MUSLIM,SPB,SPU
PER/04/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2017
115
1500000000693
RS ST ELISABETH
SEMARANG
JL KAWI NO 1 SEMARANG
8310035
YAYASAN RS ST
ELISABETH
PER/027/042015
RS.TRAUMA
CENTRE
20/04/2015
19/04/2016
116
1500000001247
RS TELOGOREJO
8446000
YAYASASAN
KESEHATAN
TELOGOREJO
PER/10/052015
RS.TRAUMA
CENTRE
19/05/2015
18/05/2017
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
200 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
117
1500000000773
8411800
YAYASAN BALA
KESELAMATAN
PER/07/042015
RS.TRAUMA
CENTRE
30/04/2015
31/03/2016
118
1500000000222
RSUD DR H SOEWONDO
KENDAL
381433
PER/025/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2017
119
1500000000222
RSUD DR H SOEWONDO
KENDAL
381433
PER/27/122015
RS.TRAUMA
CENTRE
30/12/2015
31/12/2015
120
1500000000211
RSUD DR R SOEDJATI
SOEMODIARDJO
JL DI PANJAITAN 36 PURWODADI
421004
DR BAMBANG
PUJIYANTO M.KES
PER/30/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
121
1500000000211
RSUD DR R SOEDJATI
SOEMODIARDJO
JL DI PANJAITAN 36 PURWODADI
421004
DR BAMBANG
PUJIYANTO M.KES
PER/021/022015
RS.TRAUMA
CENTRE
16/02/2015
31/12/2015
122
1400000000216
JL FATMAWATI NO 1 SEMARANG
6711500
PER/018/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
123
1400000000216
JL FATMAWATI NO 1 SEMARANG
6711500
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
124
1400000000214
RSUD TUGUREJO
7605297
PER/016/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
125
1400000000214
RSUD TUGUREJO
7605297
PER/27/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
126
7-337195525
RSUP DR KARIADI
SEMARANG
JL DR SUTOMO 16 SEMARANG
PER/13/062015
RS.TRAUMA
CENTRE
13/11/2015
31/05/2016
KANTOR CABANG
MA11222I
50245
024841399
3
KEMENTERIAN
KESEHATAN RI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
201 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000142
6499639
DR HADIASRI
WIDIYASARI
PER/15/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000142
6499639
DR HADIASRI
WIDIYASARI
PER/14/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000000143
9726555
DR ITA KUSUMAWATI
PER/16/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000144
29726555
CV GRIYA DAYA
MANDIRI
PER/17/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000001791
57171
PT NAYAKA ERA
HUSADA
PER/29/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
1500000001791
57171
PT NAYAKA ERA
HUSADA
PER/35/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1500000001215
DR DEVI FIKASARI
PER/33/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001215
DR DEVI FIKASARI
PER/27/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1400000000516
2974269
SUHADI
PER/18/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
10
1500000000106
SINGKIL RT 03 RW 08 PARANGJORO
GROGOL SUKOHARJO
2974269
PER/11/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
11
1500000000106
SINGKIL RT 03 RW 08 PARANGJORO
GROGOL SUKOHARJO
2974269
PER/10/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
12
1500000000417
KLINIK NURIFA
2601843
DR UMI ARIFAH
PER/22/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
202 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
13
1500000000417
KLINIK NURIFA
2601843
14
1100000000030
PUSKESMAS
KEBAKKRAMAT
825812
15
1400000000474
620220
16
1400000000474
17
1100000000033
RS DR OEN SURAKARTA
18
1500000001866
RS HERMINA SOLO
19
1500000001866
RS HERMINA SOLO
20
1100000000034
21
1100000000034
22
TIPE IKS
AWAL IKS
AKHIR IKS
PER/24/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PER/07/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
620220
PER/07/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
643139
PER/12/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
57116
638989
PER/30/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
57116
638989
PER/37/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
714422
PER/09/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
714422
PER/08/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000001873
783399
PER/32/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
23
1500000001873
783399
PER/38/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
24
1100000000032
RS KUSTATI
643013
PER/09/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
MA11222I
DR UMI ARIFAH
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
203 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/10/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
TNI AU SURAKARTA
PER/32/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
RS NIRMALA SURI
SUKOHARJO
PER/19/012016
RS.TRAUMA
CENTRE
15/01/2016
31/12/2016
714458
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
714458
PER/02/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
RS PANTI WALUYO
JL A YANI 1-2
712077
PER/15/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1100000000031
RS PANTI WALUYO
JL A YANI 1-2
712077
PER/39/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
32
1500000000294
RS PKU MUHAMADIYAH
SELOGIRI
5327504
YYS PKU
MUHAMADIYAH
PER/22/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
33
1500000000294
RS PKU MUHAMADIYAH
SELOGIRI
5327504
YYS PKU
MUHAMADIYAH
PER/21/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
34
1400000000537
RS PKU MUHAMADIYAH
SURAKARTA
714578
RS PKU MUHAMADIYAH
SURAKARTA
PER/20/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
35
1500000001946
RS PKU MUHAMMADIYAH
KARANGANYAR
57171
492685
YAYASAN
MUHAMADIYAH
PER/31/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
36
1500000001946
RS PKU MUHAMMADIYAH
KARANGANYAR
57171
492685
YAYASAN
MUHAMADIYAH
PER/36/072015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
25
1100000000032
RS KUSTATI
643013
26
1500000001009
780240
27
1400000000536
RS NIRMALA SURI
SUKOHARJO
JL SOLO SUKOHARJO KM 9
28
1100000000035
RS ORTHOPEDI PROF DR
SOEHARSO
29
1100000000035
RS ORTHOPEDI PROF DR
SOEHARSO
30
1100000000031
31
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
204 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
37
1500000001628
RS PKU MUHAMMADIYAH
SRAGEN
YAYASAN
MUHAMADIYAH
PER/17/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
38
1500000001628
RS PKU MUHAMMADIYAH
SRAGEN
YAYASAN
MUHAMADIYAH
PER/28/012016
RS.TRAUMA
CENTRE
01/06/2016
31/12/2016
39
08237
RS PKU MUHAMMADIYAH
SURAKARTA
JL RONGGOWARSITO SURAKARTA
RS PKU MUHAMADIYAH
SURAKARTA
PER/20/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
40
1500000001531
JL VETERAN NO 35 SRAGEN
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
41
1500000001531
JL VETERAN NO 35 SRAGEN
PER/25/012016
RS.TRAUMA
CENTRE
15/01/2016
31/12/2016
42
7-1689398627
JL A AYANI KARTASURA
KEMENKES
PER/02/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
43
1500000000121
PT TENTERAM MAKMUR
BERSAMA
PER/11/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
44
1500000000121
PT TENTERAM MAKMUR
BERSAMA
PER/13/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
45
1500000000687
JL ROKAN NO 8 SRAGEN
PER/24/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
46
1500000000687
JL ROKAN NO 8 SRAGEN
PER/27/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
47
1500000000687
JL ROKAN NO 8 SRAGEN
PER/27/042015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
48
1100000000036
RSUD DR MOEWARDI
SURAKARTA
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
714578
50771
71445832
634634
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
205 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
49
1100000000036
RSUD DR MOEWARDI
SURAKARTA
50
1500000000120
RSUD DR SOEHADI
PRIJONEGORO SRAGEN
51
1500000000120
52
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/03/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
PER/13/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
RSUD DR SOEHADI
PRIJONEGORO SRAGEN
PER/14/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000424
RSUD KABUPATEN
KARANGANYAR
495673
RSUD KABUPATEN
KARANGANYAR
PER/04/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
53
1400000000424
RSUD KABUPATEN
KARANGANYAR
495673
RSUD KABUPATEN
KARANGANYAR
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
54
1400000000425
RSUD KABUPATEN
SUKOHARJO
JL DR MOEWARDI 71 SUKOHARJO
593118
RSUD KABUPATEN
SUKOHARJO
PER/05/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
55
1400000000425
RSUD KABUPATEN
SUKOHARJO
JL DR MOEWARDI 71 SUKOHARJO
593118
RSUD KABUPATEN
SUKOHARJO
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
56
1400000000423
715300
PER/06/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
57
1400000000423
715300
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
58
1500000000458
29697090
RS SARILA HUSADA
PER/25/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
KANTOR CABANG
MA11222I
634634
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
206 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001026
KLINIK DAARUSSYIFA
5263311
DR TAUFIQ HIDAYAT
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000703
5501687
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001675
KLINIK KELUARGA
5522836
DR AGUS SAPARIYANTO
PER/20/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000000550
532149
PT NAYAKA ERA
HUSADA
PER/03/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000001705
KLINIK PKU
MUHAMMADIYAH ADIPALA
081227126
70
YAYASAN PKU
MUHAMMADIYAH
PER/21/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001057
KLINIK PKU
MUHAMMADIYAH CILACAP
521208
YAYASAN PKU
MUHAMMADIYAH
CILACAP SELATAN
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001228
KLINIK PKU
MUHAMMADIYAH KROYA
494993
YAYASAN PKU
MUHAMMADIYAH
KROYA
PER/15/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001000
KLINIK PKU
MUHAMMADIYAH
SAMPANG
5265565
PKU MUHAMMADIYAH
SAMPANG - CILACAP
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000865
5264443
DR HERI YULIADRI
PER/09/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000000762
471290
YAYASAN SWANA
SANTA PALANG BIRU
GOMBONG KEBUMEN
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1400000000491
RS PKU MUHAMMADIYAH
GOMBONG
471780
PER/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
12
1500000000866
RS PKU MUHAMMADIYAH
SRUWENG
382597
MUHAMMADIYAH
CABANG SRUWENG,
KEBUMEN
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
54352
53271
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
207 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000733
3870779
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
14
1500000000431
521725
YAYASAN MEDIATRIX
PER/02/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
15
1100000000021
RSUD CILACAP
533010
PER / 01 /
012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
16
1100000000021
RSUD CILACAP
533010
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000000702
RSUD MAJENANG
621012
RSUD MAJENANG
PER/05/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
18
1500000000701
542396
PER/04/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000727
BLKPP DI YOGYAKARTA
512619
DISNAKERTRANS DIY
PER/08/022015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1500000000400
BP PMI DI YOGYAKARTA
6499652
PMI PROP DI
YOGYAKARTA
PER/03/012016
RS.TRAUMA
CENTRE
01/03/2016
28/02/2017
1500000000400
BP PMI DI YOGYAKARTA
6499652
PMI PROP DI
YOGYAKARTA
PER/03/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
208 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000173
BP RB CITRA PARAMEDIKA
774876
YAYASAN BINANGUN
CITRA PARA MEDIKA
PER/06/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
1500000000048
9103190
CV MITRA SEHAT
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000048
9103190
CV MITRA SEHAT
PER/50/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
1500000001289
882702
PER/38/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001334
KLINIK HARMONY
DR. ERNA
PER/39/2015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001238
BALAI HIPERKES
PER/33/062015
RS.TRAUMA
CENTRE
01/06/2015
01/05/2016
10
1500000001284
RB LARAS HATI
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
1500000001285
PER/35/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
12
1500000001160
KLINIK PATALAN
DR GLORY
PER/28/052015
RS.TRAUMA
CENTRE
28/05/2015
28/05/2016
13
1500000000598
KLINIK PRATAMA
ANUGERAH
DR. AR ROYAN
PER/04/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
14
1500000001237
PER/34/2015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
15
1500000000062
JL SALAK/TURI KM 4 KADISOBO II RT 02 RW
03 TRIMULYO
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
789670
7485660
YAYASAN SWA
YOGYAKARTA
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
209 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1500000000062
JL SALAK/TURI KM 4 KADISOBO II RT 02 RW
03 TRIMULYO
7485660
YAYASAN SWA
YOGYAKARTA
PER/51/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000000063
867363
CV WIDURI
PER/53/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
18
1500000000063
867363
CV WIDURI
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
19
1500000001669
4396680
TRIYONO
PER/40/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
20
1500000001041
PUSEKSMAS PIYUNGAN
DINKES BANTUL
PER/23/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
21
1500000001037
PUSKESMAS
BAMBANGLIPURO
DINKES BANTUL
PER/17/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
22
1500000000399
PUSKESMAS
BANGUNTAPAN II
PER/04/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
23
1500000001042
PUSKESMAS DLINGO I
DINKES BANTUL
PER/21/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
24
1500000001038
PUSKESMAS IMOGIRI I
DINKES BANTUL
PER/19/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
25
1500000001067
PUSKESMAS JETIS I
DINKES BANTUL
PER/20/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
26
1500000001064
PUSKESMAS KASIHAN I
DINKES BANTUL
PER/24/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
27
1500000000802
PUSKESMAS KRETEK
PER/11/052015
RS.TRAUMA
CENTRE
08/05/2015
07/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
210 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
28
1500000001049
PUSKESMAS PAJANGAN
DINKES BANTUL
PER/25/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
29
1500000001063
PUSKESMAS PANDAK I
DINKES BANTUL
PER/18/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
30
1500000001047
PUSKESMAS PLERET
DINKES BANTUL
PER/22/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
31
1500000001039
PUSKESMAS PUNDONG
DINKES BANTUL
PER/16/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
32
1500000001048
PUSKESMAS SANDEN
DINKES BANTUL
PER/15/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
33
1500000001066
PUSKESMAS SEDAYU I
DINKES BANTUL
PER/26/052015
RS.TRAUMA
CENTRE
28/05/2015
27/05/2016
34
1500000000803
PUSKESMAS SEWON I
DINKES BANTUL
PER/10/052015
RS.TRAUMA
CENTRE
08/05/2015
07/05/2016
35
1500000000804
PUSKESMAS SRANDAKAN
DINKES BANTUL
PER/12/052015
RS.TRAUMA
CENTRE
08/05/2015
07/05/2016
36
1400000000143
RS CONDONG CATUR
887494
DR HERTI ELIZA
SILALAHI
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
37
1500000000447
RS ISLAM HIDAYATULLAH
389184
PER/07/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
38
1400000000142
RS PANTI NUGROHO
JL KALIURANG KM 17
895186
PER/06/032015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
39
1500000000449
RS PANTI RINI
496022
PER/08/03/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
211 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
40
1400000000005
RS PKU MUHAMMADIYAH
BANTUL
368238
YAYASAN
MUHAMMADIYAH
PER/45/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
41
1400000000005
RS PKU MUHAMMADIYAH
BANTUL
368238
YAYASAN
MUHAMMADIYAH
PER/25/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
42
1400000000312
RS PKU MUHAMMADIYAH
YOGYAKARTA
JL KHA DAHLAN 20
512653
YAYASAN
MUHAMMADIYAH
PER/32/062015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
43
1400000000136
RS QUEEN LATIFA
581402
PER/24/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
44
1400000000136
RS QUEEN LATIFA
581402
PER/48/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
45
1400000000139
RS RAJAWALI CITRA
7482003
DR H SUNU PRASMONO
PER/30/062015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
46
1500000001287
RSKIA PKU
MUHAMMADIYAH
KOTAGEDE
MUHAMMADIYAH
PER/37/2015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
47
1400000000654
RSPAU DR S HARDJOLUKITO
TNI AU
PER/42/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
48
1500000001033
PER/27/052015
RS.TRAUMA
CENTRE
18/05/2015
18/04/2016
49
1400000000478
JL JOGYA-SOLO KM 14 GLONDONG
TIRTOMARTANI KALASAN
498278
POLDA DI YOGYAKARTA
PER/44/122015
RS.TRAUMA
CENTRE
18/01/2016
30/11/2016
50
1500000000812
445020
PT. RSGM
PER/13/05/2015
RS.TRAUMA
CENTRE
18/05/2015
17/05/2016
51
1400000000138
JL BHAYANGKARA 48 MORANGAN
SLEMAN
868437
PEMKAB BANTUL
PER/41/062015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
444715
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
212 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
52
1500000000168
RSU KHARISMA
PARAMEDIKA
774633
YAYASAN BINANGUN
KHARISMA
PARAMEDIKA
PER/05/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
53
1500000000169
6498555
PT EMPAT MITRA
PER/07/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
54
1500000000349
867270
PER/02/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
55
1500000000349
867270
PER/02/012016
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
56
1500000000858
PER/14/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
57
1500000000327
371195
PEMKOT YOGYAKARTA
PER/01/012016
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
58
1500000000327
371195
PEMKOT YOGYAKARTA
PER/04/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
59
1400000000475
RSUD WATES
JL TENTARA PELAJAR KM 1 NO 5
773169
PER/43/122015
RS.TRAUMA
CENTRE
18/01/2016
31/10/2016
60
1500000000586
RSUP DR SARDJITO
587333
KEMENKES
PER/09/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
61
1400000000479
JL KABUPATEN KRONGGAHAN
TRIHANGGO GAMPING
4530404
UNIVERSITAS GADJAH
MADA
PER/49/122015
RS.TRAUMA
CENTRE
18/01/2016
30/11/2016
62
1400000000315
498000
PROF.DR.DR.H
LAMSUDIN
PER/22/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
63
1400000000315
498000
PROF.DR.DR.H
LAMSUDIN
PER/47/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
213 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
64
1400000000480
620333
DR BONDAN AGUS
SURYANTO
PER/46/122015
RS.TRAUMA
CENTRE
18/01/2016
30/11/2016
65
1400000000695
JL WONOSARI-YOGYA KM 7 BANDUNG
PLAYEN
394574
PT.RAHMA BAKTI
HUSADA
PER/23/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
66
1400000000695
JL WONOSARI-YOGYA KM 7 BANDUNG
PLAYEN
394574
PT.RAHMA BAKTI
HUSADA
PER/54/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
67
1400000000696
392718
PER/21/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
68
1400000000696
392718
PER/52/122015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
69
1400000000134
514014
PER/32/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
1500000001803
KLINIK PRATAMA
MARDLATILLAH
52361
1500000001805
RS BUDI RAHAYU
JL BARITO NO 5
51113
423491
1500000001799
RS MUHAMMADIYAH
RODLIYAH ACHID MOGA
52315
86267099
MA11222I
PIMPINAN
PD MUHAMMADIYAH
KABUPATEN PEMALANG
PD MUHAMMADIYAH
PEMALANG
TIPE IKS
AWAL IKS
AKHIR IKS
PER / 015 /
062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER / 08 /
052015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER / 014 /
062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
214 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000411
51211
4495222
PER / 24 /112015
RS.TRAUMA
CENTRE
01/11/2015
31/10/2016
1500000001804
RS SITI KHODIJAH
51111
422845
YAYASAN AL IRSYAD AL
ISLAMIYYAH
PER / 017 /
062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001239
RSU ARO
JL DR SOETOMO GAMER
4416443
DR BROTO RAHARDJO
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001240
420218
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1400000000008
JL PEMUDA NO 24
321251
DR WIDODO
YULIANTO,MKES M
PER/09/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001214
RSUD BENDAN
JL SRIWIJAYA NO 2
437232
DR BAMBANG
PRASETIJO
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000001806
PER / 016 /
062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001992
1500000000942
KLINIK PRATAMA
ANUGERAH HEXA
MA11222I
51117
KODE
POS
59316
IKS
TELEPON
PIMPINAN
NO IKS
437376
TIPE IKS
AWAL IKS
AKHIR IKS
DR MUSTIKO WIBOWO
PER/29/X/2015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
DR ANWAR RIYANTO
PER/015/052015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
215 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001995
1500000001666
1500000000943
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
42427610
FAQIH, SKM
PER/033/X/2015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
325784324
DR BOBY HADI
SARHASTANTO
PER/018/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KLINIK PRATAMA
MASYITHOH
440543
BP MASYITHOH
PER/019/052015
RS.TRAUMA
CENTRE
04/05/2015
30/04/2016
1500000001989
59318
4246276
DR HARIYANTO
PER/032/X/2015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
7-1073301393
KLINIK PRATAMA
SEJAHTERA
JL RA KARTINI NO 15 PATI
59111
DR JOKO MARDIYANTO
PER.030/X/2015
RS.TRAUMA
CENTRE
07/01/2016
30/09/2016
1500000001991
59318
7437747
DR CHUSNUL KHOTIMAH
PER/33/X/2015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
1500000000641
727047406
PER/13/04215
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
10
1500000000947
JL MH THAMRIN NO 14 PANGGANG
597807
PER/017/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1500000001985
RS KARTIKA HUSADA
KUDUS
432532
RS KARTIKA HUSADA
PER/0026/10201
5
RS.TRAUMA
CENTRE
01/10/2015
30/09/2017
12
1500000000334
RS MARDIRAHAYU KUDUS
434707
RS MARDIRAHAYU
PER/004/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
13
1500000001178
RS MITRA BANGSA
JL KOLONEL SUGIONO NO 75
382555
PER/28/052015
RS.TRAUMA
CENTRE
04/05/2015
30/06/2016
14
1500000001386
RS NURUSSYIFA KUDUS
4246440
RS NURUSSYIFA
PER/020/052015
RS.TRAUMA
CENTRE
04/05/2015
30/04/2017
MA11222I
59316
59317
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
216 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/014/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
RS PKU
MUHAMMADIYAH
PER/009/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
532257
RS PKU
MUHAMMADIYAH
PER/022/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
4150645
DR INDAH RESTIYANTI
PER/018/052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
RS UMUM DAERAH
KABUPATEN KUDUS
444001
PER/008/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2016
1500000000335
531666
PER/10/032015
RS.TRAUMA
CENTRE
01/03/2015
31/03/2016
21
1500000000642
YKM NU
PER/011/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
22
1500000000138
591507
PER/003/012016
RS.TRAUMA
CENTRE
02/02/2016
31/12/2017
23
1500000000138
591507
PER/003/01/2015
RS.TRAUMA
CENTRE
20/01/2015
20/01/2016
24
05896
434707
YAYASAN KRISTEN
KESEJAHTERAAN MARDI
RAHAYU
1482/DIR/PKS/I/
2016
RS.TRAUMA
CENTRE
19/01/2016
01/12/2016
25
05896
434707
YAYASAN KRISTEN
KESEJAHTERAAN MARDI
RAHAYU
PER/001/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
26
1500000000164
RSU DR R SOETIJONO
BLORA
JL DR SUTOMO NO 42
531118
RSU DR R SOETIJONO
PER/004/012016
RS.TRAUMA
CENTRE
02/02/2016
31/12/2017
15
1500000000661
RS PERMATA
JL REKSODIPURO NO 57
531624
16
1500000001387
RS PKU MUHAMADIYAH
MAYONG
4256500
17
1500000001678
RS PKU MUHAMMADIYAH
BLORA
18
1500000001389
19
1400000000314
20
MA11222I
58217
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
217 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
27
1500000000164
RSU DR R SOETIJONO
BLORA
JL DR SUTOMO NO 42
531118
RSU DR R SOETIJONO
PER/001/012015
RS.TRAUMA
CENTRE
12/01/2015
31/12/2015
28
1500000001667
4199008
DR ARDILLA S
PER/021/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
29
1400000000465
RSUD DOKTER R
SOETRASNO REMBANG
691444
RSUD DOKTER R
SOETRASNO REMBANG
PER/027/092015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
30
7-1061786476
59319
029144400
1
PEMERINTAH DAERAH
440/327/23.01.01
/2015
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
31
1500000001986
RSUD DR R SOEPRAPTO
CEPU
58218
421026
RSUD DR SEPRAPTO
CEPU
PER/0026/08201
5
RS.TRAUMA
CENTRE
01/08/2015
31/07/2016
32
7-1511265053
RSUD KELET
59454
910/1448.B/X/20
15
RS.TRAUMA
CENTRE
20/01/2016
31/10/2017
33
1400000000558
RSUD RA KARTINI
KABUPATEN JEPARA
591175
RSUD JEPARA
PER/004/01/2015
RS.TRAUMA
CENTRE
12/01/2015
31/01/2016
34
1400000000249
381102
445/31/062014
RS.TRAUMA
CENTRE
01/06/2015
35
7-1601479543
DR. SUWORO
NURCAHYONO.M.KES
PER/009/012016
RS.TRAUMA
CENTRE
26/01/2016
31/12/2016
36
1500000000944
471321
PRATOMO WIDODO
PER/016/052015
RS.TRAUMA
CENTRE
04/05/2015
30/04/2016
37
1400000000427
432008
PER/028/092015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2017
38
7-1061786478
295386111
SWASTA
8784/KSH/PKS/
XI/2015
RS.TRAUMA
CENTRE
12/01/2016
01/09/2017
MA11222I
59163
59163
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
218 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
39
1500000000137
RUMAH SAKIT
KUMALASIWI KUDUS
4245551
RUMAH SAKIT
KUMALASIWI KUDUS
PER/005/2016
RS.TRAUMA
CENTRE
02/02/2016
31/12/2017
40
1500000000137
RUMAH SAKIT
KUMALASIWI KUDUS
4245551
RUMAH SAKIT
KUMALASIWI KUDUS
PER/002/01/2015
RS.TRAUMA
CENTRE
21/01/2015
31/12/2015
41
7-1534312103
59346
DR KHRISNA NUGRAHA
W
PER/001/012016
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
42
7-1534989054
59431
PER/0035/11201
5
RS.TRAUMA
CENTRE
21/01/2016
31/12/2016
43
1500000001668
JL DR SOETOMO NO.45
RUMKITBAN.84.08.05
BLORA
PER/023/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001889
KLINIK PRATAMA
BRASTOMOLO
08355
RS PKU MUHAMMADIYAH
PURWOREJO
1500000000112
1500000000112
MA11222I
22898046
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
713656429
SUPARJA
PER/09/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
325260
PER/10/072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
RS PKU MUHAMMADIYAH
TEMANGGUNG
596704
PIMPINAN DAERAH
MUHAMMADIYAH
TEMANGGUNG
PER/20/122014
RS.TRAUMA
CENTRE
01/07/2015
31/10/2015
RS PKU MUHAMMADIYAH
TEMANGGUNG
596704
PIMPINAN DAERAH
MUHAMMADIYAH
TEMANGGUNG
PER/20/122014
RS.TRAUMA
CENTRE
01/11/2015
31/12/2015
56229
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
219 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
368950
YAYASAN
KESEJAHTERAAN ISLAM
KOTA MAGELANG
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
596008
YAYASAN YAKKUM
PER/05/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
RST DR SOEDJONO
JL URIP SUMOHARJO NO 48
362813
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000001874
1400000000467
10
1400000000467
11
1500000001798
1500000001234
1400000000020
56115
322096
YAYASAN KRISTEN
UNTUK KESEHATAN
UMUM
PER/08/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
325260
PER/18/112014
RS.TRAUMA
CENTRE
01/07/2015
31/10/2015
325260
PER/18/112014
RS.TRAUMA
CENTRE
01/11/2015
31/12/2015
7-1712506763
RSUD DR TJITROWARDOJO
PURWOREJO
275321118
RSUD DR
TJITROWARDOJO
PURWOREJO
PER/01/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2017
12
1400000000023
RSUD KABUPATEN
TEMANGGUNG
JL DR SUTOMO NO 67
491119
PER/17/112014
RS.TRAUMA
CENTRE
01/07/2015
31/10/2015
13
1400000000023
RSUD KABUPATEN
TEMANGGUNG
JL DR SUTOMO NO 67
491119
PER/17/112014
RS.TRAUMA
CENTRE
01/11/2015
31/12/2015
14
1400000000021
RSUD SETJONEGORO
WONOSOBO
JL RUMAH SAKIT NO 1
321091
PER/24/122014
RS.TRAUMA
CENTRE
01/11/2015
31/12/2015
15
1400000000452
587372
PIMPINAN PUSAT
MUHAMMADIYAH
PER/14/102014
RS.TRAUMA
CENTRE
01/07/2015
31/10/2015
16
1400000000452
587372
PIMPINAN PUSAT
MUHAMMADIYAH
PER/14/102014
RS.TRAUMA
CENTRE
01/11/2015
31/12/2015
MA11222I
54112
54114
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
220 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1500000000113
322961
PER/02/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2017
18
1500000000113
322961
PER/01/012015
RS.TRAUMA
CENTRE
29/01/2016
31/12/2015
19
1500000000113
322961
PER/01/012015
RS.TRAUMA
CENTRE
01/07/2015
31/10/2015
20
1500000000113
322961
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
30/06/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001580
KLINIK AZ-ZAHRA
DR M KARIM AMRULLAH
PER/09/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001580
KLINIK AZ-ZAHRA
DR M KARIM AMRULLAH
PER/09/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001579
KLINIK KS TUBUN 81
081828983
6
DR SUHARJO
PER/10/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001579
KLINIK KS TUBUN 81
081828983
6
DR SUHARJO
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001755
KLINIK SEJAHTERA 1
7608142
DR NAJMUL IMAN
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
52194
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
221 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001755
KLINIK SEJAHTERA 1
52194
7608142
DR NAJMUL IMAN
PER/12/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001756
KLINIK SEJAHTERA 2
52194
7608142
DR NAJMUL IMAN
PER/13/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001756
KLINIK SEJAHTERA 2
52194
7608142
DR NAJMUL IMAN
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1200000000015
673481
DR KHOSIATUN AZMI
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
10
1200000000015
673481
DR KHOSIATUN AZMI
PER/05/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
0900000000036
JL AHMAD YANI NO 57
672525
DR IRMA YURITA
PER/02/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
12
0900000000036
JL AHMAD YANI NO 57
672525
DR IRMA YURITA
PER/02/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1500000000186
RS MITRA SIAGA
322550
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
14
1500000000186
RS MITRA SIAGA
322550
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
15
1000000000009
3448180
DR H. ACHMAD
SHOCHIBUL BIRRI
PER/06/012015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
16
1000000000009
3448180
DR H. ACHMAD
SHOCHIBUL BIRRI
PER/06/012015
RS.TRAUMA
CENTRE
01/07/2015
17
1500000001754
RSU ADELLA
491154
DR H M ABDUL DJALIL
MKES
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
MA11222I
52419
31/12/2015
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
222 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
18
1500000001754
RSU ADELLA
19
01626
20
0800000000030
41059007
21
0900000000035
JL DR SUTOMO NO 63 SLAWI
22
0900000000035
JL DR SUTOMO NO 63 SLAWI
23
7-1033158771
24
1500000001236
RSUD SURADADI
25
1500000001236
RSUD SURADADI
26
0900000000029
27
0900000000029
KANTOR CABANG
MA11222I
PIMPINAN
AWAL IKS
AKHIR IKS
PER/11/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
PER/14/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
DR H FAISAL AMRI, SH
PER/07/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
491991
DR WIDODO JOKO
MULYONO, M,KES,MMR
PER/04/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
491991
DR WIDODO JOKO
MULYONO, M,KES,MMR
PER/04/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
PEMKOT TEGAL
PER/14/112015
RS.TRAUMA
CENTRE
17/12/2015
31/12/2016
3336263
PEMERINTAH
KABUPATEN TEGAL
PER/08/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
3336263
PEMERINTAH
KABUPATEN TEGAL
PER/08/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
JL ABABIL NO 42
353387
HABIYAH. MMR
PER/03/2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
JL ABABIL NO 42
353387
HABIYAH. MMR
PER/03/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
52419
491154
52122
DR H M ABDUL DJALIL
MKES
TIPE IKS
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
223 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
081393306
461
7-1549815415
024760562
1
1500000000102
337334
1500000000102
337334
1500000000102
337334
1500000000688
KLINIK PKU
MUHAMMADIYAH CAWAS
897661
1500000000444
KLINIK PKU
MUHAMMADIYAH POLAN
HARJO
557002
1500000001520
3283734
1500000000083
10
1500000000083
11
1500000001869
JL DELANGGU POLANHARJO NO 41
REJOSARI SABRANG
12
1500000000293
1400000000435
MA11222I
57322
57411
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PER/24/112015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
PER/07/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
YAYASAN
MUHAMMADIYAH CAB
JATINOM KLATEN
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
YAYASAN
MUHAMMADIYAH CAB
JATINOM KLATEN
PER/06/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/05/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/15/062015
RS.TRAUMA
CENTRE
22/06/2015
21/05/2016
327453
PER/05/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
327453
PER/01/JKK/012
015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
552215
PT PRABAWATAMA
INDONESIA
PER/17/072015
RS.TRAUMA
CENTRE
23/07/2015
22/06/2016
8850400
PER/03/032015
RS.TRAUMA
CENTRE
02/03/2015
29/02/2016
PT RESTU BUNDA
YAYASAN DANA
PENSIUN KARYAWAN
BPJS
KETENAGAKERJAAN
YAYASAN
MUHAMMADIYAH CAB
JATINOM KLATEN
YAYASAN
MUHAMMADIYAH
CABANG CAWAS
PIMPINAN CABANG
MUHAMMADIYAH
POLANHARJO
KABUPATEN KLATEN
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
224 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1400000000147
RS HIDAYAH BOYOLALI
324614
YAYASAN DUA
SEPTEMBER BOYOLALI
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
1500000001975
7910812
YAYASAN RS ISLAM
BANYUBENING
PER/22/102015
RS.TRAUMA
CENTRE
12/10/2015
11/09/2016
15
1500000000445
RS KARANGGEDE SISMA
MEDIKA
610600
PT SISMADI
MEDCORPINDO
BOYOLALI
PER/06/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
16
0800000000001
RSI KLATEN
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
0800000000001
RSI KLATEN
PER/18/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
18
1500000000292
YAYASAN KARTIKA
HUSADA SAMBI
PER/04/032015
RS.TRAUMA
CENTRE
02/03/2015
29/02/2016
19
7-1550676406
JL. MERBABU NO 7
PT CAKRA HUSADA
PER/08/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
20
0800000000004
JL KANTIL 14 BOYOLALI
PER/19/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
21
0800000000004
JL KANTIL 14 BOYOLALI
PER/02/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
22
1100000000010
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
23
0800000000002
RSU SOERADJI
TIRTONEGORO
JL SURADJI TIRTONEGORO
PER/04/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
24
0800000000002
RSU SOERADJI
TIRTONEGORO
JL SURADJI TIRTONEGORO
PER/218/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
MA11222I
3294459
57412
322898
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
225 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
0800000000005
RSUD BANYUDONO
JL RAYA SOLO-SEMARANG
085647136
655
PEMDA
PER/03/012016
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
26
0800000000005
RSUD BANYUDONO
JL RAYA SOLO-SEMARANG
085647136
655
PEMDA
PER/20/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
27
1400000000253
551051
YAYASAN
MUHAMMADIYAH
CABANG DELANGGU
PER/16/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000603
BKMM KABUPATEN
BANYUMAS
635602
PER/18/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
1400000000575
BP PMI PURBALINGGA
891359
PER/36/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
1500000000627
KLINIK ANASTASIA
BAMBANG WP
PER/20/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000418
KLINIK KURNIA
5295250
YAYASAN IMAM
CHALIFAH
PER/09/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000571
KLINIK PKU
MUHAMMADIYAH
PURBALINGGA
758808
PDM PURBALINGGA
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000629
JL ADYAKSA NO 8 PURWOKERTO
636842
PMI BANYUMAS
PER/23/052015
RS.TRAUMA
CENTRE
01/05/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
226 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/10/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PER/12/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
SUHARNO
PER/15/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
6440963
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
53353
758678
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
53362
895680
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
PUSKESMAS BOJONGSARI
(PURBALINGGA)
53362
6596981
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001696
PUSKESMAS BUKATEJA
(PURBALINGGA)
53382
476050
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
15
1500000001695
PUSKESMAS KALIGONDANG
(PURBALINGGA)
53331
7057884
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
16
1500000001697
PUSKESMAS KALIKAJAR
(PURBALINGGA)
53331
893379
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
17
1500000001686
PUSKESMAS KALIMANAH
(PURBALINGGA)
53371
892414
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
18
1500000001688
PUSKESMAS
KARANGANYAR
(PURBALINGGA)
7632913
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000000117
JL INPRES NO 20 TAMBAKSARI
1500000000626
KLINIK UMP
1500000000351
JL MARTADIREJA II NO 32 PURWOKERTO
642484
10
1500000001090
11
1500000001700
PUSKESMAS BOBOTSARI
(PURBALINGGA)
12
1500000001679
PUSKESMAS BOJONG
(PURBALINGGA)
13
1500000001682
14
MA11222I
SETYOWATI INDRAYANI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
227 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
19
1500000001694
PUSKESMAS
KARANGJAMBU
(PURBALINGGA)
20
1500000001703
PUSKESMAS
KARANGMONCOL
(PURBALINGGA)
JL.RY BOBOTSARI-REMBANG KM 11 DS
PEPEDAN PURBALINGGA KEC
KARANGMONCOL RT 1 RW 8
21
1500000001693
PUSKESMAS KARANGREJA
(PURBALINGGA)
22
1500000001685
23
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7619971
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
7621793
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
JL JL RAYA KARANGREJA KM 2
PURBALINGGA
7609219
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
PUSKESMAS
KARANGTENGAH
(PURBALINGGA)
6599857
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001699
PUSKESMAS KEJOBONG
(PURBALINGGA)
082281219
3
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
24
1500000001692
PUSKESMAS KEMANGKON
(PURBALINGGA)
53381
6591566
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
25
1500000001680
PUSKESMAS KUTASARI
(PURBALINGGA)
53361
6599183
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
26
1500000001698
PUSKESMAS KUTAWIS
(PURBALINGGA)
JL.RY BUKATEJA-KUTAWIS KM 5
PURBALINGGA RT 1 RW 5
53382
7639694
DR NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
27
1500000001702
PUSKESMAS MREBET
(PURBALINGGA)
53352
758186
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
28
1500000001689
PUSKESMAS PADAMARA
(PURBALINGGA)
53372
6598588
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
29
1500000001701
PUSKESMAS PENGADEGAN
(PURBALINGGA)
53393
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
30
1500000001677
PUSKESMAS PURBALINGGA
53319
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
53355
891862
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
228 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
31
1500000001704
PUSKESMAS REMBANG
(PURBALINGGA)
53356
6590539
DR.NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
32
1500000001681
PUSKESMAS SERAYU
LARANGAN (PURBALINGGA)
53352
7635303
DR NONOT MULYONO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
33
1500000000604
RS EMANUEL
479030
YAKKUM
PER/21/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
34
0900000000001
RS ORTHOPAEDI
PURWOKERTO
6844166
PER/35/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
35
1500000000628
RS SINAR KASIH
JL MARTADIREJA II PURWOKERTO
638370
PER/22/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
36
1400000000179
RS WIJAYAKUSUMA
633062
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
37
1500000000416
RSI BANJARNEGARA
082138783
429
DR. H SETYOKO M
PER/17/03/2015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
38
1400000000187
RSI PURWOKERTO
JL H MASYHURI NO 39 PURWOKERTO
630019
YARSI PURWOKERTO
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
39
1400000000187
RSI PURWOKERTO
JL H MASYHURI NO 39 PURWOKERTO
630019
YARSI PURWOKERTO
PER/001/012016
RS.TRAUMA
CENTRE
21/01/2016
31/12/2017
40
1500000000680
RSKB JATIWINANGUN
JL JATIWINANGUN NO 54 PURWOKERTO
638169
PT SANATIO
PER/19/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
41
1400000000282
JL MAYJEND SUNGKONO NO 1
PURBALINGGA
892222
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
42
1400000000238
RSUD AJIBARANG
JL RAYA PANCASAN
6570004
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
YAKKUM
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
229 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
43
1500000000467
RSUD BANYUMAS
796031
PER/07/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
44
1400000000399
RSUD DR R GOETENG
TAROENADIBRATA
JL TENTARA PELAJAR NO 22
896645
PER/37/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
45
1500000001279
591464
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
46
1500000000118
JL DR GUMBREG NO 1 PURWOKERTO
632708
PER/11/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
47
1500000000350
892844
PER/16/032015
RS.TRAUMA
CENTRE
02/03/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000867
1500000001918
KLINIK "COCA-COLA"
1400000000657
1400000000657
MA11222I
YAYASAN NIRMALA
HUSADA
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/03/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
JULIUS ROBIYANTO
PER/14/082015
RS.TRAUMA
CENTRE
24/08/2015
24/08/2016
522888
H AGUNG WAHONO
SH.MHUM
PER/10/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
522888
H AGUNG WAHONO
SH.MHUM
PER/06/012016
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
522914
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
230 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001574
KLINIK PRATAMA
"MANUNGGAL"
322480
KOPERASI PT DAMATEX
PER/09/062015
RS.TRAUMA
CENTRE
22/06/2015
31/12/2015
1500000001917
KLINIK PRATAMA
KALIMASADHA
9546050
DR CHOIRUL ANAM
PER/13/082015
RS.TRAUMA
CENTRE
20/08/2015
20/08/2016
7-631760693
029871237
8
LILIS WIJAYANTI
PER/15/112015
RS.TRAUMA
CENTRE
26/11/2015
19/11/2016
1400000000656
526225
SITI MUSRIYATUN
PER/05/012016
RS.TRAUMA
CENTRE
13/01/2016
31/12/2016
1400000000656
526225
SITI MUSRIYATUN
PER/11/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
10
1500000000341
PUSKESMAS BAWEN
591539
DINAS KESEHATAN
KAB.SEMARANG
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
11
1500000000340
PUSKESMAS BERGAS
6525695
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
12
1500000000338
PUSKESMAS DUREN
711355
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
13
1500000000325
PUSKESMAS GETASAN
2838099
DINAS KESEHATAN
KAB.SEMARANG
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
14
1500000000337
PUSKESMAS JAMBU
593532
DINAS KESEHATAN
KAB.SEMARANG
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
15
1500000000339
PUSKESMAS PRINGAPUS
25721150
DNIAS KESEHATAN
KAB.SEMARANG
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
16
1500000000336
PUSKESMAS SUMOWONO
40575050
DINAS KESEHATAN
KAB.SEMARANG
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
MA11222I
50661
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
231 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
17
1500000000343
PUSKESMAS SURUH
2882262
DINAS KESEHATAN
KAB.SEMARANG
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
18
1500000000342
PUSKESMAS SUSUKAN
615066
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
19
1500000000344
PUSKESMAS TENGARAN
DINAS KESEHATAN
KAB.SEMARANG
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
20
1400000000016
RS PURI ASIH
323209
DR MUFTI SIRADJ,SPOG
PER/04/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
21
1400000000016
RS PURI ASIH
323209
DR MUFTI SIRADJ,SPOG
PER/18/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1400000000019
RSUD AMBARAWA
591020
PER/02/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
23
1400000000019
RSUD AMBARAWA
591020
PER/16/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
7-1395288578
PEMKOT SALATIGA
PER/03/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
25
1400000000101
JL OSAMALIKI NO. 19
324074
PER/17/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
01728
RSUD SALATIGA
JL OSAMALIKI NO 19 SALATIGA
324074
KOTA MAGELANG
PER/03/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
27
1400000000018
RSUD UNGARAN
6921006
PEMDA KAB.SEMARANG
PER/15/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
28
1400000000018
RSUD UNGARAN
6921006
PEMDA KAB.SEMARANG
PER/01/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
MA11222I
50721
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
232 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001891
50111
6734367
PER / 27 /
072015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1500000001891
50111
6734367
PER/15/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000001494
089671458
335
NINDYA ANGGI
SINANTARA
PER / 19 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001494
089671458
335
NINDYA ANGGI
SINANTARA
PER/09/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000000967
JL WOLTERMONGINSIDI NO 93,
PEDURUNGAN, SEMARANG
6714465
PER / 12 /
052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
1500000000921
3549735
PER / 12 /
052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
1500000001534
082180099
759
PER/12/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
1500000001534
082180099
759
PER / 23 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001532
082180099
759
PER / 21 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
10
1500000001532
082180099
759
PER/10/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
11
1500000001533
082180099
759
PER / 22 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001533
082180099
759
PER/11/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
233 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1400000000261
70572297
PT NAYAKA ERA
HUSADA SEMARANG
PER / 04 /
012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
14
1400000000261
70572297
PT NAYAKA ERA
HUSADA SEMARANG
PER/04/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
15
1500000001381
JL SEMARANG-DEMAK KM 15 WONOKERTO
KARANGTENGAH DEMAK
7605621
PT NAYAKA ERA
HUSADA SEMARANG
PER / 16 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
16
1500000001381
JL SEMARANG-DEMAK KM 15 WONOKERTO
KARANGTENGAH DEMAK
7605621
PT NAYAKA ERA
HUSADA SEMARANG
PER/08/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
17
1500000001380
7605621
PT NAYAKA ERA
HUSADA SEMARANG
PER / 17 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
18
1500000001380
7605621
PT NAYAKA ERA
HUSADA SEMARANG
PER/07/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
19
1500000001807
76580381
PER/14/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
20
1500000001807
76580381
PER / 24 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
21
1500000001539
6591137
PER / 20 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
22
1500000001539
6591137
PER/13/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
23
1500000001333
6719222
PER / 18 /
062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
24
1500000001333
6719222
PER/06/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
234 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1500000001035
76743362
PER / 13 /
052015
RS.TRAUMA
CENTRE
04/05/2015
03/05/2016
26
1300000000006
JL JOGOLOYO NO 09 DEMAK
685723
PER/02/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
27
1300000000006
JL JOGOLOYO NO 09 DEMAK
685723
PER / 03 /
012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
28
1100000000006
6580019
DR MASYHUDI,MSI
PER/01/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2017
29
1100000000006
6580019
DR MASYHUDI,MSI
PER / 01 /
012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
30
1300000000033
JL CITARUM NO 98 SEMARANG
3546040
DR SUSETYO, SPA
PER / 02 /
012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
31
1300000000033
JL CITARUM NO 98 SEMARANG
3546040
DR SUSETYO, SPA
PER/03/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
32
1400000000402
685018
PER/05/012016
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
1500000000715
MA11222I
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
031715542
59
SUSILO
HENDROWARSITO
PER/09/012015
TIPE IKS
RS.TRAUMA
CENTRE
AWAL IKS
01/01/2016
AKHIR IKS
31/12/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
235 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000715
031715542
59
SUSILO
HENDROWARSITO
PER/15/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000717
081130514
3
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000717
081130514
3
PER/14/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000720
5675589
PER/13/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000720
5675589
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000712
BP 14
70701255
DR SURANADI SUGANDA
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000712
BP 14
70701255
DR SURANADI SUGANDA
PER/10/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001466
BRAIN CLINIC
5018800
PER/11/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1500000001466
BRAIN CLINIC
5018800
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
11
1500000001555
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001030
7319619
PER/12/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1500000001030
7319619
PER/20/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
236 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
14
1500000001031
0315944122
PER/12/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
15
1500000001031
0315944122
PER/21/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
16
1500000000719
KLINIK HEALTHY
5040990
PER/13/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000000719
KLINIK HEALTHY
5040990
PER/12/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
18
1500000001071
8498880
KLINIK KENCANA
MEDIKA
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
19
1500000001071
8498880
KLINIK KENCANA
MEDIKA
PER/14/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
20
1500000000716
JL.AMBENGAN 35 SURABAYA
081832211
9
PER/16/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
21
1500000000716
JL.AMBENGAN 35 SURABAYA
081832211
9
PER/15/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
22
1500000001072
KLINIK MEDPOINT
7524067
KLINIK MEDPOINT
PER/16/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23
1500000001072
KLINIK MEDPOINT
7524067
KLINIK MEDPOINT
PER/23/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
24
1500000001072
KLINIK MEDPOINT
7524067
KLINIK MEDPOINT
PER/23/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
25
1500000001487
5677088
PT.PERKEBUNAN
NUSANTARA X
(PERSERO)
PER/06/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
237 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
26
1500000001487
5677088
PT.PERKEBUNAN
NUSANTARA X
(PERSERO)
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
27
1400000000445
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28
1400000000445
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
29
1400000000450
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
30
1400000000450
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
31
1400000000449
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
32
1400000000449
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
33
1500000000713
KLINIK PRATAMA 65
088835356
66
DR ADRIANUS MICHAEL
FOEH
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
34
1500000000713
KLINIK PRATAMA 65
088835356
66
DR ADRIANUS MICHAEL
FOEH
PER/18/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
35
1500000000718
KLINIK PRATAMA
ALAMANDA
5677767
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
36
1500000000718
KLINIK PRATAMA
ALAMANDA
5677767
PER/19/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
37
1500000000718
KLINIK PRATAMA
ALAMANDA
5677767
PER/11/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
238 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
38
1400000000443
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
39
1400000000443
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
40
1400000000439
JL CENDRAWASIH NO 28B
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
41
1400000000439
JL CENDRAWASIH NO 28B
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
42
1400000000446
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
43
1400000000446
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
44
1400000000447
JL PANDEGILING NO 117A
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
45
1400000000447
JL PANDEGILING NO 117A
7887273
PT NAYAKA ERA
HUSADA
PER/17/012015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
46
1400000000448
JL TANDES ASRI NO 64
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
47
1400000000448
JL TANDES ASRI NO 64
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
48
1400000000451
JL KALI RUNGKUT NO 52
7887273
PT NAYAKA ERA
HUSADA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
49
1400000000451
JL KALI RUNGKUT NO 52
7887273
PT NAYAKA ERA
HUSADA
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
239 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
50
1500000001483
KLINIK PRATAMA PG
KREMBOONG
081332074
648
PTPN X
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
51
1500000001483
KLINIK PRATAMA PG
KREMBOONG
081332074
648
PTPN X
PER/24/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
52
1500000001483
KLINIK PRATAMA PG
KREMBOONG
081332074
648
PTPN X
PER/06/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
53
1500000001484
KLINIK PRATAMA PG
TOELANGAN
PTPN X
PER/06/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
54
1500000001484
KLINIK PRATAMA PG
TOELANGAN
PTPN X
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
55
1500000001484
KLINIK PRATAMA PG
TOELANGAN
PTPN X
PER/24/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
56
1500000001485
KLINIK PRATAMA PG
WATOETOELIS
081332074
648
PTPN X
PER/24/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
57
1500000001485
KLINIK PRATAMA PG
WATOETOELIS
081332074
648
PTPN X
PER/06/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
58
1500000001485
KLINIK PRATAMA PG
WATOETOELIS
081332074
648
PTPN X
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
59
1500000001486
KLINIK ST.VINCENTIUS A
PAULO (KARAH)
5677562
YAYASAN ARNOLDUS
PER/20/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
60
1500000001486
KLINIK ST.VINCENTIUS A
PAULO (KARAH)
5677562
YAYASAN ARNOLDUS
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
61
1500000001029
7327688
YAYASAN KASIH
KARUNIA
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
240 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
62
1500000001029
63
1500000001558
POLIKLINIK BIDDOKKES A.
YANI (SATKES MERTOJOSO)
64
1500000001556
65
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
AWAL IKS
AKHIR IKS
PER/21/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
POLRES PELABUHAN
TANJUNG PERAK
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001559
POLRESTABES SURABAYA
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
66
1500000000478
RS BHAKTI DHARMA
HUSADA
7404444
PEMERINTAH KOTA
SURABAYA
PER/06/01/2015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
67
1500000000478
RS BHAKTI DHARMA
HUSADA
7404444
PEMERINTAH KOTA
SURABAYA
PER/07/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
68
0700000000013
RS BHAYANGKARA HS
SAMSOERI M
8292227
POLDA JATIM
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
69
0700000000013
RS BHAYANGKARA HS
SAMSOERI M
8292227
POLDA JATIM
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
70
1500000000714
RS MARINIR EWA
PANGALILA GUNUNGSARI
JL GOLF I NO 1A SURABAYA
0315663539
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
71
1500000000714
RS MARINIR EWA
PANGALILA GUNUNGSARI
JL GOLF I NO 1A SURABAYA
0315663539
PER/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
72
1500000001385
RS MATA UNDAAN
5343806
RS MATA UNDAAN
PER/22/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
73
1500000001385
RS MATA UNDAAN
5343806
RS MATA UNDAAN
PER/24/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
7327688
YAYASAN KASIH
KARUNIA
TIPE IKS
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
241 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
74
1500000000549
JL KESATRIAN NO 17
5611272
KODAM V BRAWIJAYA
PER/03/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
75
1500000000549
JL KESATRIAN NO 17
5611272
KODAM V BRAWIJAYA
PER/07/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
76
1500000000187
RS TNI AU SOEMITRO
SURABAYA
5662593
TNI AU
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
77
1500000000187
RS TNI AU SOEMITRO
SURABAYA
5662593
TNI AU
PER/05/022015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
78
1500000001384
RS UNIVERSITAS
AIRLANGGA
8439473
UNIVERSITAS
AIRLANGGA
PER/08/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
79
1500000001384
RS UNIVERSITAS
AIRLANGGA
8439473
UNIVERSITAS
AIRLANGGA
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
80
1500000000711
5310069
DRG.OUTI
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
81
1500000000711
5310069
DRG.OUTI
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
82
1400000000360
5686161
PER/23/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
83
1400000000360
5686161
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
84
1500000001557
SAT BRIMOB
PER/06/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
85
1500000001201
PER/18/052015
RS.TRAUMA
CENTRE
19/05/2015
19/05/2016
MA11222I
8290071
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
242 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000000732
1400000000662
1500000000731
1500000000730
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
PER/22/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
KLINIK PRATAMA
RAWAT JALAN MITRA
HUSADA I
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000000933
PER/12/052015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001620
POLIKLINIK POLRES
KEDIRI
PER/18/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1500000001619
POLIKLINIK POLRES
KOTA KEDIRI
PER/17/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1500000001622
POLIKLINIK POLRES
NGANJUK
POLIKLINIK POLRES
NGANJUK
PER/19/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1000000000008
RS BHAYANGKARA KEDIRI
POLRI
PER/33/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1000000000008
RS BHAYANGKARA KEDIRI
POLRI
PER/24/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1000000000008
RS BHAYANGKARA KEDIRI
POLRI
PER/18/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
12
07189
RS BHAYANGKARA
NGANJUK
PER/23/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
395066
7660694
3218896
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
243 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
POLRI
PER/5113/12201
5
RS.TRAUMA
CENTRE
28/12/2015
31/12/2016
671939
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
671939
PER/31/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
RSU MUHAMMADIYAH
SURYA MELATI
441748
RSU MUHAMMADIYAH
SURYA MELATI
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
0800000000031
RSUD GAMBIRAN
JL.K.H.WAHID HASYIM NO 64
773097
DR.ENDANG WAHYU
L,MARS
PER/19/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
18
0800000000031
RSUD GAMBIRAN
JL.K.H.WAHID HASYIM NO 64
773097
DR.ENDANG WAHYU
L,MARS
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
19
1500000001542
391718
RSUD KABUPATEN
KEDIRI
PER/16/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
20
1500000001542
391718
RSUD KABUPATEN
KEDIRI
PER/29/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21
1400000000564
RSUD KERTOSONO
551118
PER/17/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1400000000564
RSUD KERTOSONO
551118
PER/25/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23
1500000000863
476376
YAYASAN ARGA
HUSADA UTAMA
PER/28/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
24
1500000000863
476376
YAYASAN ARGA
HUSADA UTAMA
PER/11/052015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
13
04783
14
1500000000725
15
1500000000725
16
1500000001258
17
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
244 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1400000000421
RUMAH SAKIT
BHAYANGKARA NGANJUK
3218896
KEPOLISIAN REPUBLIK
INDONESIA
PER/21/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
1500000000940
391047
RS PTP XXI
TOELOENGREDJO
PER/13/052015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
27
1500000000940
391047
RS PTP XXI
TOELOENGREDJO
PER/30/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28
1400000000206
RUMAH SAKIT
MUHAMMADIYAH AHMAD
DAHLAN
773115
MKKM PD
MUHAMMADIYAH KOTA
KEDIRI
PER/20/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
29
1400000000206
RUMAH SAKIT
MUHAMMADIYAH AHMAD
DAHLAN
773115
MKKM PD
MUHAMMADIYAH KOTA
KEDIRI
PER/27/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
30
1500000000723
RUMAH SAKIT
MUHAMMADIYAH SITI
KHODIJAH
545481
RUMAH SAKIT
MUHAMMADIYAH SITI
KHODIJAH
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
31
1500000000723
RUMAH SAKIT
MUHAMMADIYAH SITI
KHODIJAH
545481
RUMAH SAKIT
MUHAMMADIYAH SITI
KHODIJAH
PER/32/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
32
1500000001259
778165
YAYASAN PONPES
HIDAYATUL MUBTADIEN
PER/15/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
33
1500000001637
687801
PER/20/062015
RS.TRAUMA
CENTRE
01/07/2015
31/12/2015
1500000000659
391583
PEMERINTAH PROVINSI
JAWA TIMUR DINAS
TENAGA KERJA
TRANSMIGRASI DAN
KEPENDUDUKAN
PER/03/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
34
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
245 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000919
796858
PT.NAYAKA ERA
HUSADA
PER/158I/052015
RS.TRAUMA
CENTRE
19/05/2015
18/05/2016
1500000000916
496261
PT.NAYAKA ERA
HUSADA
PER/158/052015
RS.TRAUMA
CENTRE
19/05/2015
18/05/2016
1500000001672
PER/177/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001673
JL PAHLAWAN TRIP NO 1
65111
551356
DR AKHMAD PRABOWO
PER/178/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001676
65153
4949699
PER/180/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1300000000016
594161
YAYASAN BAPTIS
INDONESIA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1300000000016
594161
YAYASAN BAPTIS
INDONESIA
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1200000000012
597023
PER/03/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1200000000012
597023
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
10
1200000000008
393000
ABNASAMANHUDI
SAUTIKA HUSADA PT
PER/11/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1200000000008
393000
ABNASAMANHUDI
SAUTIKA HUSADA PT
PER/11/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
12
1500000000046
RSI GONDANGLEGI
879047
YAYASAN RS
GONDANGLEGI
PER/04/01/01201
6
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
246 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000046
RSI GONDANGLEGI
879047
YAYASAN RS
GONDANGLEGI
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
14
1400000000002
326688
YAY AL MADINAH
PER/12/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
15
1400000000002
326688
YAY AL MADINAH
PER/12/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
16
1200000000009
426705
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1200000000009
426705
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
18
1200000000010
460558
SUJIATI, SST,MM.KES
PER/08/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
19
1200000000010
460558
SUJIATI, SST,MM.KES
PER/08/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
20
7-375291327
RSUD LAWANG
JL RA KARTINI 5 LAWANG
PEMERINTAH
PER/183/092015
RS.TRAUMA
CENTRE
02/12/2015
31/08/2016
21
1500000000920
824002
YAYASAN PELAYANAN
KESEHATAN BALA
KESELAMATAN
PER/159/052015
RS.TRAUMA
CENTRE
20/05/2015
19/05/2016
22
7-938470983
65313
341591054
DR.RACHMAD ARI
IRMAWAN
PER/184/092015
RS.TRAUMA
CENTRE
31/12/2015
31/08/2016
23
1500000001674
JL MT HARYONO 139
65144
551356
DR H TRIWAHYU
SARWIYATA
PER/179/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
24
1000000000011
458919
DR.KRISTIWI
HANGGRIYANI
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
65213
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
247 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
25
1000000000011
458919
DR.KRISTIWI
HANGGRIYANI
PER/06/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1000000000011
458919
DR.KRISTIWI
HANGGRIYANI
PER/14/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
27
1000000000013
331100
DRG.BENNY ANDOKO
WIBISONO
PER/07/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
28
1000000000013
331100
DRG.BENNY ANDOKO
WIBISONO
PER/ 07/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
29
1000000000012
JL.BANJARARUM SELATAN NO 3
MONDOROKO-SINGOSARI MALANG
458679
DR.SADI HARIONO
PER/09/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
30
1000000000012
JL.BANJARARUM SELATAN NO 3
MONDOROKO-SINGOSARI MALANG
458679
DR.SADI HARIONO
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
31
1200000000011
837777
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
32
1200000000011
837777
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
33
1400000000001
362101
PEMPROV JATIM
PER/10/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
34
1400000000001
362101
PEMPROV JATIM
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
35
1400000000001
362101
PEMPROV JATIM
PER/10/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
36
7-1238038834
341591036
PROVINSI
PER/13/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
65311
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
248 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
37
1500000001316
458055
PER/157/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
38
1500000001316
458055
PER/15/012016
RS.TRAUMA
CENTRE
04/02/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
POLDA JATIM
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
338044
POLDA JATIM
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
889022
POLDA JATIM
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
PT ROLAS NUSANTARA
MEDIKA JEMBER
PER/06/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
082336624
828
DR EKA WARDHANI
PER/22/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
88646
POLDA JATIM
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
422701
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001593
JL JEND A YANI 29
1500000001592
JL RA KARTINI 17
1500000001590
1500000000652
JL GAJAH MADA NO 15
1400000000625
RS BHAYANGKARA
BONDOWOSO
1500000001561
RS BHAYANGKARA TK III
LUMAJANG
1500000001591
RS BINA SEHAT
MA11222I
KODE
POS
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
249 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-1672273183
RS CITRA HUSADA
68117
033148620
0
YAYASAN CITRA
HUSADA
PER/004/012016
RS.TRAUMA
CENTRE
01/02/2016
31/01/2017
7-1672273183
RS CITRA HUSADA
68117
033148620
0
YAYASAN CITRA
HUSADA
PER/4/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
10
1400000000626
RS ISLAM LUMAJANG
887999
DR R ELYUNAR DWI
NUGROHO
PER/20/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
7-1692033973
RS JEMBER KLINIK
033148710
4
PT NUSANTARA MEDIKA
UTAMA
PER/05/012016
RS.TRAUMA
CENTRE
28/01/2016
31/12/2016
12
1500000000647
RSD DR SOEBANDI
JL DR SOEBANDI NO 124
487441
PER/05/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
13
1500000000647
RSD DR SOEBANDI
JL DR SOEBANDI NO 124
487441
PER/05/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
14
1400000000009
485967
PT ROLAS NUSANTARA
MEDIKA
PER/21/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
15
1400000000009
485967
PT ROLAS NUSANTARA
MEDIKA
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
16
1400000000009
485967
PT ROLAS NUSANTARA
MEDIKA
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
17
7-777708533
RSUD DR H KOESNADI
BONDOWOSO
00000
DR AGUS SUWARDJITO,
M KES
PER/16/102015
RS.TRAUMA
CENTRE
02/12/2015
30/09/2016
18
7-1938064553
67311
PEMPROV
PER/007/022016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
19
1500000000957
JL RAMBIPUJI 19 BALUNG
PEMDA
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
68111
033488166
6
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
250 / 322
09-02-2016
18:49:59
NO
20
KODE PROVIDER
1500000000956
KANTOR CABANG
NO
NAMA PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
233388695
PEMDA
PER/07/052015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/05/2015
AKHIR IKS
30/04/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001062
BP JAMSOSTEK 22
7764043
CV CITRA MEDIKA
IKS/25/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
1500000001062
BP JAMSOSTEK 22
7764043
CV CITRA MEDIKA
IKS/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001061
BP JAMSOSTEK 51
747731
CV CITRA MEDIKA
IKS/25/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
1500000001061
BP JAMSOSTEK 51
747731
CV CITRA MEDIKA
IKS/10/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001651
POLRI
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2017
1500000001649
POLRI
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2017
1500000001644
POLRI
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2017
1500000001647
FKTP POLRES
PROBOLINGGO
POLRI
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2017
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
251 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001336
KLINIK CITRA 10
854335
CV CITRA MEDIKA
IKS/25/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
10
1500000001336
KLINIK CITRA 10
854335
CV CITRA MEDIKA
IKS/11/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1500000001340
KLINIK CITRA 2
843346
CV CITRA MEDIKA
IKS/25/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
12
1500000001340
KLINIK CITRA 2
843346
CV CITRA MEDIKA
IKS/15/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1500000001339
KLINIK CITRA 6
4430181
CV CITRA MEDIKA
IKS/25/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
14
1500000001339
KLINIK CITRA 6
4430181
CV CITRA MEDIKA
IKS/14/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
15
1500000001338
612244
CV CITRA MEDIKA
IKS/25/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
16
1500000001338
612244
CV CITRA MEDIKA
IKS/13/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000001337
482366
CV CITRA MEDIKA
IKS/12/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
18
1500000001337
482366
CV CITRA MEDIKA
IKS/25/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
19
1500000001045
881459
CV MITRA HUSADA
IKS/08/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
20
1500000001045
881459
CV MITRA HUSADA
IKS/23/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
252 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
21
1500000001040
KLINIK MITRA 82
6640508
IKS/23/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
22
1500000001040
KLINIK MITRA 82
6640508
IKS/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23
1500000001044
KLINIK MITRA 91
655291
CV MITRA HUSADA
IKS/07/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
24
1500000001044
KLINIK MITRA 91
655291
CV MITRA HUSADA
IKS/23/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
25
1500000001043
KLINIK MITRA 95
636028
CV MITRA HUSADA
IKS/23/05/2015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
26
1500000001043
KLINIK MITRA 95
636028
CV MITRA HUSADA
IKS/06/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
27
1500000001052
637367
IKS/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28
1500000001052
637367
IKS/24/052015
RS.TRAUMA
CENTRE
25/05/2015
31/12/2015
29
1500000000768
RS BHAYANGKARA PUSDIK
BRIMOB WATUKOSEK
336050343
BRIMOB
PER/22/042015
RS.TRAUMA
CENTRE
28/04/2015
28/04/2017
30
1500000001233
RS RIZANI HUSADA
773444
PT RIZANI HUSADA
IKS/16/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
31
1500000001233
RS RIZANI HUSADA
773444
PT RIZANI HUSADA
IKS/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
32
1400000000264
RSI MASYITHOH
741018
YAYASAN
PER/27/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
253 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
33
1400000000264
RSI MASYITHOH
741018
YAYASAN
IKS/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
34
1400000000605
RSUD BANGIL
744900
IKS/29/122015
RS.TRAUMA
CENTRE
21/12/2015
31/12/2016
35
1400000000432
JL MAYJEND PANJAITAN 65
433119
DR BAMBANG AGUS
SUWIGNYA
IKS/28/112015
RS.TRAUMA
CENTRE
21/12/2015
31/12/2016
36
1500000000514
421073
DR. SUDARMANTO
PER/19/042015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2015
37
1500000000087
RSUD TONGAS
511836
DRG KAMALIYAH
TJIPLUK P.L, MMKES
IKS/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
38
1500000000087
RSUD TONGAS
511836
DRG KAMALIYAH
TJIPLUK P.L, MMKES
PER/01/012015
RS.TRAUMA
CENTRE
13/01/2015
31/12/2015
39
1400000000604
846877
DR ANANG BUDI
Y.M.MKES
IKS/30/122015
RS.TRAUMA
CENTRE
21/12/2015
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001601
BP JAMSOSTEK 106
61385
6817998
IR H TEUKU ISMAIL
PER/48/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001601
BP JAMSOSTEK 106
61385
6817998
IR H TEUKU ISMAIL
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
254 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000346
KLINIK ASY-SYIFA
61453
885995
DR ELDYANTO YUYUN
PER/09/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
1500000000346
KLINIK ASY-SYIFA
61453
885995
DR ELDYANTO YUYUN
PER/55/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001603
61311
323302
CV GALUH MERALDA
PER56/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001603
61311
323302
CV GALUH MERALDA
PER/20/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001606
KLINIK EMMA
61352
CV BANGUN SESAMA
DAMAI SEJAHTERA
PER/46/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001606
KLINIK EMMA
61352
CV BANGUN SESAMA
DAMAI SEJAHTERA
PER/24/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1400000000107
61385
6817979
MARIA MEILITASARI
HARLIN DR, SPPD, MARS
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
10
1400000000107
61385
6817979
MARIA MEILITASARI
HARLIN DR, SPPD, MARS
PER/54/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1500000001597
KLINIK KELUARGA
BAHAGIA
61371
513355
NOVEL MOHAMMAD
RAMZY PUTRA
PER/45/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
12
1500000001597
KLINIK KELUARGA
BAHAGIA
61371
513355
NOVEL MOHAMMAD
RAMZY PUTRA
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
13
1500000001604
61461
DR WARTIK
PER/51/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
14
1500000001604
61461
DR WARTIK
PER/21/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
255 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
15
1500000001607
KLINIK MITRA 39
61471
DR BETTY ENDAH
WARNI MKES
PER/23/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
16
1500000001607
KLINIK MITRA 39
61471
DR BETTY ENDAH
WARNI MKES
PER/53/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000001582
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
18
1500000001588
JL. BHAYANGKARA
PER/30/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
19
1500000001589
KLINIK POLRES
MOJOKERTO
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
20
1500000001598
JL ANGGREK NO 24 CANDIMULYO
61411
878318
DR MERIDIAN GEODESI
PER/47/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21
1500000001598
JL ANGGREK NO 24 CANDIMULYO
61411
878318
DR MERIDIAN GEODESI
PER/15/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
22
1500000001605
61453
DR WIWIET SARASWATI
PER/52/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
23
1500000001605
61453
DR WIWIET SARASWATI
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
24
1500000001599
61362
492876
CV MITRA HUSADA
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
25
1500000001599
61362
492876
CV MITRA HUSADA
PER/49/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1500000001600
JL RAYA JETIS NO 14
61352
363786
IR H TEUKU ISMAIL
PER/17/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
861843
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
256 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
IR H TEUKU ISMAIL
PER/50/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
61384
PER/44/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
61384
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
YAYASAN PERMATA
MOJOKERTO
PER/19/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
PER/32/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2017
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
30/06/2015
PER/43/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
331234
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
JL GAJAHMADA NO 54
323252
PER/34/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
PUSKESMAS KEDUNDUNG
JL BY PASS KEDUNDUNG
392028
PER/33/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001585
PUSKESMAS MENTIKAN
JL PRAPANCA NO 55 PRAJURITKULON
321057
PER/35/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001583
PUSKESMAS WATES
330144
PER/37/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
27
1500000001600
JL RAYA JETIS NO 14
61352
28
1500000001595
29
1500000001595
30
1500000001602
31
1500000001581
PULONITI, BANGSAL
32
1500000001596
61384
33
1500000001596
61384
34
1500000001584
PUSKESMAS BLOOTO
35
1500000001586
PUSKESMAS GEDONGAN
36
1500000001587
37
38
MA11222I
363786
397355
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
257 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
39
1500000001608
RS AL AZIZ
61453
853757
YAYASAN AL AZIZ
PER/25/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
40
1500000001608
RS AL AZIZ
61453
853757
YAYASAN AL AZIZ
PER/67/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
41
1400000000481
RS DHARMA HUSADA
61385
6817833
HJ YUNI SETIJO
SOEKORINI
PER/41/112015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
42
1400000000463
RS DR MOEDJITO
DWIDJOSISWOJO
61411
864308
PT MOEDJITO
DWIDJOSISWOJO
PER/40/112015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
43
0900000000027
JL RAYA IJEN NO 67
61311
032132873
7
DR MAGDALENA
SITORUS
PER/05/012014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
44
0900000000027
JL RAYA IJEN NO 67
61311
032132873
7
DR MAGDALENA
SITORUS
PER/64/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
45
1500000000353
RS GATOEL
61319
328557
PT NUSANTARA MEDIKA
UTAMA
PER/07/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
46
1500000000353
RS GATOEL
61319
328557
PT NUSANTARA MEDIKA
UTAMA
PER/63/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
47
1500000000927
RS KAMAR MEDIKA
330066
PER/65/122015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
48
1500000000927
RS KAMAR MEDIKA
330066
PER/11/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
49
1400000000510
RS MAWADDAH MEDIKA
61384
596666
PT WILUJENG ABADI
SEJAHTERA
PER/42/112015
RS.TRAUMA
CENTRE
22/12/2015
31/12/2016
50
1500000000925
RS MUTIARA HATI
61351
363442
SULFAKAR DR SPOG
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
258 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
51
1500000000925
RS MUTIARA HATI
52
1500000001594
RS NAHDLATUL ULAMA
JOMBANG
53
1500000001594
54
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
363442
SULFAKAR DR SPOG
PER/66/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
878700
PT RUMAH SAKIT
NAHDLATUL ULAMA
JOMBANG
PER/69/122015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
RS NAHDLATUL ULAMA
JOMBANG
878700
PT RUMAH SAKIT
NAHDLATUL ULAMA
JOMBANG
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001522
RS PELENGKAP MEDICAL
CENTER
JL IR JUANDA NO 03
61411
877945
PT PELANGKAP MEDICA
SEJAHTERA
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
55
1500000001522
RS PELENGKAP MEDICAL
CENTER
JL IR JUANDA NO 03
61411
877945
PT PELANGKAP MEDICA
SEJAHTERA
PER/68/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
56
0800000000011
61381
598621
DR MARIA M HARLIM
SP.PD
PER/60/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
57
0800000000011
61381
598621
DR MARIA M HARLIM
SP.PD
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
58
0800000000034
61382
596900
DR HR SETIOHARTONO
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
59
0800000000034
61382
596900
DR HR SETIOHARTONO
PER/62/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
60
1500000001523
RSI HASANAH
321635
PIMPINAN WILAYAH
MUHAMMADIYAH JAWA
TIMUR
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
61
1500000001523
RSI HASANAH
321635
PER/70/122015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
62
1500000001621
RSI JOMBANG
JL BRIGJEN KRETARTO NO 22 A
PER/58/122015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
MA11222I
61351
61411
860074
PIMPINAN WILAYAH
MUHAMMADIYAH JAWA
TIMUR
YAYASAN AMAL
SHOLEH IKATAN
PERSAUDARAAN HAJI
INDONESIA
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
259 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
63
1500000001621
RSI JOMBANG
JL BRIGJEN KRETARTO NO 22 A
61411
860074
YAYASAN AMAL
SHOLEH IKATAN
PERSAUDARAAN HAJI
INDONESIA
PER/38/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
64
0800000000033
JL R A BASUNI NO 12
61361
321922
DR SULAIMAN ROSYID
PER/61/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
65
0800000000033
JL R A BASUNI NO 12
61361
321922
DR SULAIMAN ROSYID
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
66
1500000001623
RSU KARTINI
JL AIRLANGGA NO 37 MOJOSARI
592261
YAYASAN KARTINI
PER/39/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
67
0800000000010
61382
591591
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
68
0800000000010
61382
591591
PER/59/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
69
1500000000347
JL MERDEKA NO 59 MOJOWARNO
61475
495093
YAYASAN KESEHATAN
GKJW
PER/08/032015
RS.TRAUMA
CENTRE
01/03/2015
31/12/2015
70
1500000000347
JL MERDEKA NO 59 MOJOWARNO
61475
495093
YAYASAN KESEHATAN
GKJW
PER/57/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
1500000001578
MA11222I
NAMA PROVIDER
BALAI PENGOBATAN
POLRES BANYUWANGI
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
421060
PER/06/062015
TIPE IKS
RS.TRAUMA
CENTRE
AWAL IKS
22/06/2015
AKHIR IKS
31/12/2015
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
260 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
1500000001577
BALAI PENGOBATAN
POLRES SITUBONDO
1500000000827
KLINIK BRAWIJAYA
JL BRAWIJAYA NO 46 KEBALENAN
423711
1500000000827
KLINIK BRAWIJAYA
JL BRAWIJAYA NO 46 KEBALENAN
1500000000832
1500000000832
TIPE IKS
AWAL IKS
AKHIR IKS
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
31/12/2015
DR EDI HERMANTO
PER/07/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
423711
DR EDI HERMANTO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
592890
PIMPINAN CABANG
MUHAMMADIYAH
MUNCAR
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
592890
PIMPINAN CABANG
MUHAMMADIYAH
MUNCAR
PER/08/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000367
RS AL HUDA
842033
PER/16/102015
RS.TRAUMA
CENTRE
28/12/2015
31/12/2016
1200000000005
RS YASMIN
421198
YAYASAN SUMBER
WARAS
PER/18/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1200000000005
RS YASMIN
421198
YAYASAN SUMBER
WARAS
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1400000000010
KRIKILAN GLENMORE
821118
PT ROLAS NUSANTARA
MEDIKA
PER/19/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
11
1400000000010
KRIKILAN GLENMORE
821118
PT ROLAS NUSANTARA
MEDIKA
PER/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
12
1500000001552
RSUD ASEMBAGUS
SITUBONDO
452193
PER/09/052015
RS.TRAUMA
CENTRE
22/06/2015
31/12/2015
13
1500000001552
RSUD ASEMBAGUS
SITUBONDO
452193
PER/06/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
261 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
14
1500000001392
RSUD BESUKI
JL OLAHRAGA NO 55 BESUKI
891118
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
15
1500000001392
RSUD BESUKI
JL OLAHRAGA NO 55 BESUKI
891118
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
16
1400000000672
RSUD BLAMBANGAN
BANYUWANGI
421118
PEMDA BANYUWANGI
PER/20/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
17
1400000000672
RSUD BLAMBANGAN
BANYUWANGI
421118
PEMDA BANYUWANGI
PER/03/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
18
1400000000470
JL ANGGREK 68
671028
PEMDA SITUBONDO
PER/17/122015
RS.TRAUMA
CENTRE
28/12/2015
31/12/2016
19
1500000000826
RSUD GENTENG
BANYUWANGI
JL HASANUDDIN NO 98 GENTENG
845839
PER/05/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
20
1500000000826
RSUD GENTENG
BANYUWANGI
JL HASANUDDIN NO 98 GENTENG
845839
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
21
1500000001576
672054
PER/10/062015
RS.TRAUMA
CENTRE
22/06/2015
31/12/2015
22
1500000001576
672054
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
262 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001665
BIDDOKKES POLRES
MADIUN
459725
PER/068/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001670
BIDDOKKES POLRESTA
MADIUN
JL SUMETERA NO 28
465455
PER/069/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000857
JL THAMRIN NO 99 MADIUN
462439
PER/32/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000786
PUSKESMAS BALEREJO
383798
PER/46/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000774
PUSKESMAS BANGUNSARI
368601
PER/34/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000938
PUSKESMAS BANJAREJO
456322
PER/60/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000780
PUSKESMAS DAGANGAN
367079
PER/40/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000939
PUSKESMAS DEMANGAN
464308
PER/61/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000784
PUSKESMAS DIMONG
458123
PER/44/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
10
1500000000777
PUSKESMAS GANTRUNG
367743
PER/37/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1500000000778
PUSKESMAS GEGER
367158
PER/38/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
12
1500000000794
PUSKESMAS GEMARANG
PER/54/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
CV BHAKTI NADINA
CORPORATE
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
263 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000000781
PUSKESMAS JETIS
367664
PER/41/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
14
1500000000782
PUSKESMAS JIWAN
465023
PER/42/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
15
1500000000779
PUSKESMAS KAIBON
455636
PER/39/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
16
1500000000795
PUSKESMAS KARE
3406616
PER/55/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
17
1500000000776
PUSKESMAS KEBONSARI
JL UTERAN KEBONSARI NO 13 DS
SINGGAHAN KEC KEBONSARI
367991
PER/36/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
18
1500000000799
PUSKESMAS KLAGENSERUT
499761
PER/59/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
19
1500000000798
PUSKESMAS KLECOREJO
388155
PER/58/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
20
1500000000791
PUSKESMAS KREBET
PER/51/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
21
1500000000783
PUSKESMAS MADIUN
458271
PER/43/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
22
1500000000936
PUSKESMAS MANGUHARJO
464661
PER/64/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
23
1500000000789
PUSKESMAS MEJAYAN
JL PANGLIMA SUDIRMAN NO 52 DS
MEJAYAN KEC.MEJAYAN
384543
PER/49/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
24
1500000000775
PUSKESMAS MLILIR
368098
PER/35/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
264 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
25
1500000000797
PUSKESMAS MOJOPURNO
26
1500000000934
27
1500000000937
PUSKESMAS PATIHAN
28
1500000000790
29
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/57/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
464402
PER/62/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
462272
PER/65/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PUSKESMAS PILANG
KENCENG
383536
PER/50/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000792
PUSKESMAS SARADAN
PER/52/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
30
1500000000785
PUSKESMAS SAWAHAN
468434
PER/45/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
31
1500000000787
PUSKESMAS SIMO
JL RAYA BALEREJO-MUNENG NO 96 DS
SIMO KEC BALEREJO
661631
PER/47/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
32
1500000000793
PUSKESMAS SUMBERSARI
384456
PER/53/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
33
1500000000935
PUSKESMAS TAWANGREJO
483997
PER/63/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
34
1500000000788
PUSKESMAS WONOASRI
PER/48/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
35
1500000000796
PUSKESMAS WUNGU
494048
PER/56/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
36
1400000000150
JL MAYJEND SUNGKONO NO 38
464822
PER/82/102015
RS.TRAUMA
CENTRE
31/12/2015
30/04/2016
MA11222I
PP MUHAMMADIYAH
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
265 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
37
1400000000149
RSU DARMAYU
38
1500000001809
39
1500000001246
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
63252
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
481320
PT DARMAYU PURI
KENCANA
PER/00X/042015
RS.TRAUMA
CENTRE
29/12/2015
30/04/2016
747888
HJ SRI YATIN SE
PER/69/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
PER/33/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
383166
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001631
POLRES BLITAR
POLRES BLITAR
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2016
1500000001632
JL. P. SUDIRMAN 32
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2016
1500000001629
POLRES TRENGGALEK
POLRES TRENGGALEK
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2016
1500000001630
POLRES TULUNGAGUNG
POLRES TULUNGAGUNG
PER/06/062015
RS.TRAUMA
CENTRE
22/06/2015
21/06/2016
1500000001915
RS SYUHADA HAJI
JL TANJUNG NO 158
801607
YAYASAN MONUMEN
SYUHADA HAJI
PER/03/062015
RS.TRAUMA
CENTRE
25/06/2015
24/06/2017
1500000000224
323186
R. H LAITUPA
ABDULMUTALIB
PER/01/012015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2017
MA11222I
66122
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
266 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-1579046012
JL KALIMANTAN NO 113
66133
(0342)8011
18
PEMKOT BLITAR
PER/02/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
7-1575901783
JL DR SOECIPTO NO 5
66184
034269100
6
PEMKAB BLITAR
PER/01/012016
RS.TRAUMA
CENTRE
25/01/2016
31/12/2016
1500000000831
RUMAH SAKIT
BHAYANGKARA
TULUNGAGUNG
321203
DR. SUMARSONO,
SP.RAD, MM
PER/02/052015
RS.TRAUMA
CENTRE
05/05/2015
04/05/2017
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001625
FASKES POLRES
BANGKALAN
PER/08/062015
RS.TRAUMA
CENTRE
22/06/2015
30/06/2017
1500000001627
FASKES POLRES
PAMEKASAN
PER/07/062015
RS.TRAUMA
CENTRE
22/06/2015
30/06/2017
1500000001624
PER/09/062015
RS.TRAUMA
CENTRE
22/06/2015
30/06/2017
1500000001626
JL URIP SUMOHARJO 35
PER/10/062015
RS.TRAUMA
CENTRE
22/06/2015
30/06/2017
1500000001553
DR H ACHMAD FURQON
PER/06/062015
RS.TRAUMA
CENTRE
24/06/2015
30/06/2016
1400000000233
PUSKESMAS TLANAKAN
PUSKESMAS
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
325568
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
267 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000233
PUSKESMAS TLANAKAN
325568
PUSKESMAS
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000437
RS LUKAS BANGKALAN
3095148
PHILIP
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1400000000436
JL DR CIPTO NO 42 SUMENEP
662494
PER/03/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1500000000633
RSUD DR H SLAMET
MARTODIRJO PAMEKASAN
326242
PER/03/042015
RS.TRAUMA
CENTRE
27/04/2015
30/04/2016
11
1500000000235
RSUD SAMPANG
JL RAJAWALI NO 10
323956
PER/02/022015
RS.TRAUMA
CENTRE
25/02/2015
31/12/2015
12
1500000000235
RSUD SAMPANG
JL RAJAWALI NO 10
323956
PER/02/022016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1400000000520
3095088
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000753
BP MITRA 30
451058
IR T ISMAIL
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000800
BP MITRA 5
JL DR CIPTO NO 129
892665
IR T ISMAIL
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
268 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000752
BP MITRA 6
JL WR SUPRATMAN NO 35
321394
IR T ISMAIL
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000751
BP MITRA 8
JL ANDANWANGI NO 43
7722188
IR T ISMAIL
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001638
DOKKES POLRES
BOJONEGORO
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001636
DOKKES POLRES
LAMONGAN
PER/17/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001633
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1400000000538
RS BHAYANGKARA WAHYU
TUTUKO BOJONEGORO
888786
PER/10/122014
RS.TRAUMA
CENTRE
21/12/2015
31/12/2016
1300000000045
661412
PER/20/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
10
1300000000045
661412
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
11
1300000000047
RS NAHDLATUL ULAMA
(NU) TUBAN
328244
DR DIDIK SUHARSOYO
MM MARS
PER/01/01215
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
12
1300000000047
RS NAHDLATUL ULAMA
(NU) TUBAN
328244
DR DIDIK SUHARSOYO
MM MARS
PER/21/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1500000000747
321010
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
14
1500000000517
RSUD.DR.SOEGIRI.
LAMONGAN
321718
PER/4/042015445/352/413.209/
2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
269 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
15
1500000001403
331056
DR.H.TOMY OEKY
PRASISKA
PER/15/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1500000001402
887749
DR.M.NAQVI ALFARISI
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000354
8944584
DR DRS H SOEHARTO SH
PER/12/032015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
1400000000600
8679727
IR SAD INDAH
AMBARWATI
PER/19/122015
RS.TRAUMA
CENTRE
21/12/2015
30/11/2016
1500000000917
KLINIK HABIBAH
JL RAYA CANGKRING RT 07 RW 02
KREMBUNG
8856706
DR WIWIK SETYORINI
PER/15/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000918
KLINIK HABIBAH 2
8979631
DR WIWIK SETYORINI
PER/15/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001652
PER/06/062016
RS.TRAUMA
CENTRE
22/06/2015
21/06/2017
1500000000172
8911555
PER/08/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
1500000000605
KRIYANDAS NURANI
58834697
PER/13/042015
FFS
01/04/2015
31/03/2016
MA11222I
CV NURANI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
270 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001401
PUSKESMAS
BALONGBENDO
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001401
PUSKESMAS
BALONGBENDO
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
10
1500000001372
PUSKESMAS
BARENGKRAJAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1500000001372
PUSKESMAS
BARENGKRAJAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001363
PUSKESMAS BUDURAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1500000001363
PUSKESMAS BUDURAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
14
1500000001354
PUSKESMAS CANDI
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
15
1500000001354
PUSKESMAS CANDI
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
16
1500000001368
PUSKESMAS GANTING
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000001368
PUSKESMAS GANTING
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
18
1500000001367
PUSKESMAS GEDANGAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
19
1500000001367
PUSKESMAS GEDANGAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
271 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
20
1500000001352
PUSKESMAS JABON
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
21
1500000001352
PUSKESMAS JABON
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
22
1500000001346
PER/16/062016
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
23
1500000001346
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
24
1500000001356
PUSKESMAS KEPADANGAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
25
1500000001356
PUSKESMAS KEPADANGAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1500000001344
PUSKESMAS KREMBUNG
PER/16/062016
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
27
1500000001344
PUSKESMAS KREMBUNG
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
28
1500000001371
PUSKESMAS KRIAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
29
1500000001371
PUSKESMAS KRIAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
30
1500000001366
PUSKESMAS MEDAENG
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
31
1500000001366
PUSKESMAS MEDAENG
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
272 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
32
1500000001345
PUSKESMAS PORONG
PER/16/062016
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
33
1500000001345
PUSKESMAS PORONG
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
34
1500000001343
PUSKESMAS PRAMBON
PER/16/062016
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
35
1500000001343
PUSKESMAS PRAMBON
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
36
1500000001364
PUSKESMAS SEDATI
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
37
1500000001364
PUSKESMAS SEDATI
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
38
1500000001361
PUSKESMAS
SEKARDANGAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
39
1500000001361
PUSKESMAS
SEKARDANGAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
40
1500000001359
PUSKESMAS SIDOARJO
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
41
1500000001359
PUSKESMAS SIDOARJO
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
42
1500000001358
PUSKESMAS SUKODONO
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
43
1500000001358
PUSKESMAS SUKODONO
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
273 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
44
1500000001369
PUSKESMAS TAMAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
45
1500000001369
PUSKESMAS TAMAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
46
1500000001353
PUSKESMAS
TANGGULANGIN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
47
1500000001353
PUSKESMAS
TANGGULANGIN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
48
1500000001342
PUSKESMAS TARIK
PER/16/062016
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
49
1500000001342
PUSKESMAS TARIK
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
50
1500000001370
PUSKESMAS TROSOBO
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
51
1500000001370
PUSKESMAS TROSOBO
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
52
1500000001355
PUSKESMAS TULANGAN
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
53
1500000001355
PUSKESMAS TULANGAN
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
54
1500000001360
PUSKESMAS URANGAGUNG
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
55
1500000001360
PUSKESMAS URANGAGUNG
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
274 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
56
1500000001365
PUSKESMAS WARU
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
57
1500000001365
PUSKESMAS WARU
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
58
1500000001357
PUSKESMAS WONOAYU
PER/26/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
59
1500000001357
PUSKESMAS WONOAYU
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
60
1400000000563
RS BHAYANGKARA PUSDIK
GASUM PORONG
JL RAYA PORONG NO 1
852104
POLRI
PER/18/122015
RS.TRAUMA
CENTRE
21/12/2015
30/11/2016
61
1400000000128
RS BUNDA SIDOARJO
8668880
PT PERMATA BUNDA
BERSAMA
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
62
1400000000128
RS BUNDA SIDOARJO
8668880
PT PERMATA BUNDA
BERSAMA
PER/25/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
63
0800000000036
RS CITRA MEDIKA
JL.RAYA SURABAYA-MOJOKERTO KM 44
361000
PER/21/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
64
0800000000036
RS CITRA MEDIKA
JL.RAYA SURABAYA-MOJOKERTO KM 44
361000
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
65
1500000000736
8921233
PER/14/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
66
1300000000030
RS SITI KHODIJAH
7882123
YYS MUHAMMADIYAH
PER/23/12205
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
67
1300000000030
RS SITI KHODIJAH
7882123
YYS MUHAMMADIYAH
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
275 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
68
1400000000278
8974943
PER/22/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
69
1400000000278
8974943
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
70
1200000000014
RSU JASEM
JL KH SAMANHUDI NO 85
8962129
YAYASAN USADA
KARYA
PER/24/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
71
1200000000014
RSU JASEM
JL KH SAMANHUDI NO 85
8962129
YAYASAN USADA
KARYA
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
72
0700000000008
RSUD SIDOARJO
JL MAJAPAHIT NO 667
8961649
PER/20/122015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
73
0700000000008
RSUD SIDOARJO
JL MAJAPAHIT NO 667
8961649
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000811
BP PANGLIMA SUDIRMAN
GRESIK
JL PANGLIMA SUDIRMAN
085631864
35
YUNI HIDAYATI
PER/12/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000811
BP PANGLIMA SUDIRMAN
GRESIK
JL PANGLIMA SUDIRMAN
085631864
35
YUNI HIDAYATI
PER/12/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
1500000001618
PER/14/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
276 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/14/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
085631864
35
YUNI HIDAYATI
PER/11/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
MANYAR RESORT
085631864
35
YUNI HIDAYATI
PER/11/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
KLINIK KELUARGA
BAHAGIA
81180888
NOVEL MUHAMMAD
RAMZY
PER/17/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000893
3981865
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000000893
3981865
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
10
1500000001569
PUSKESMAS
BALONGPANGGANG GRESIK
RAYA KEDUNGPRING 8
BALONGPANGGANG GRESIK
7921007
DR RINI SULISTYOASIH
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
11
1500000001569
PUSKESMAS
BALONGPANGGANG GRESIK
RAYA KEDUNGPRING 8
BALONGPANGGANG GRESIK
7921007
DR RINI SULISTYOASIH
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
12
1500000001572
PUSKESMAS BENJENG
GRESIK
7921167
DR SONY
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
13
1500000001572
PUSKESMAS BENJENG
GRESIK
7921167
DR SONY
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
14
1500000001492
PUSKESMAS BUNGAH
GRESIK
3949600
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
15
1500000001492
PUSKESMAS BUNGAH
GRESIK
3949600
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
1500000001618
1500000000810
MANYAR RESORT
1500000000810
1400000000627
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
277 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1500000000757
7990007
DR LESTARI
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
17
1500000000757
7990007
DR LESTARI
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
18
1500000001573
PUSKESMAS DADAP
KUNING GRESIK
7990510
DR GATOT PURNOMO
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
19
1500000001573
PUSKESMAS DADAP
KUNING GRESIK
7990510
DR GATOT PURNOMO
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
20
1500000001570
70953980
DR SOESILO
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
21
1500000001570
70953980
DR SOESILO
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
22
1500000000741
PUSKESMAS DRIYOREJO
GRESIK
23264794
DR DANIEL SA'U
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
23
1500000000741
PUSKESMAS DRIYOREJO
GRESIK
23264794
DR DANIEL SA'U
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
24
1500000001571
PUSKESMAS DUDUK
SAMPEYAN GRESIK
3903118
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
25
1500000001571
PUSKESMAS DUDUK
SAMPEYAN GRESIK
3903118
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1500000001489
3949299
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
27
1500000001489
3949299
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
278 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
28
1500000000742
PUSKESMAS GENDING
GRESIK
JL VETERAN GRESIK
3985872
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
29
1500000000742
PUSKESMAS GENDING
GRESIK
JL VETERAN GRESIK
3985872
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
30
1500000000892
PUSKESMAS INDUSTRI
GRESIK
3985877
DRG ANISAH
MAHMUDAH
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
31
1500000000892
PUSKESMAS INDUSTRI
GRESIK
3985877
DRG ANISAH
MAHMUDAH
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
32
1500000000890
PUSKESMAS
KARANGANDONG GRESIK
7911659
DR SITI HAFIDA
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
33
1500000000890
PUSKESMAS
KARANGANDONG GRESIK
7911659
DR SITI HAFIDA
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
34
1500000000894
PUSKESMAS KEBOMAS
GRESIK
3985880
DR. RAHAJU
NUGRAHANI
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
35
1500000000894
PUSKESMAS KEBOMAS
GRESIK
3985880
DR. RAHAJU
NUGRAHANI
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
36
1500000000755
PUSKESMAS KEDAMEAN
GRESIK
7911437
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
37
1500000000755
PUSKESMAS KEDAMEAN
GRESIK
7911437
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
38
1500000001565
PUSKESMAS KEPATIHAN
GRESIK
7991403
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
39
1500000001565
PUSKESMAS KEPATIHAN
GRESIK
7991403
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
279 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
40
1500000001566
PUSKESMAS KESAMBEN
KULON GREIK
60438431
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
41
1500000001566
PUSKESMAS KESAMBEN
KULON GREIK
60438431
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
42
1500000001617
PUSKESMAS MANYAR
GRESIK
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
43
1500000001617
PUSKESMAS MANYAR
GRESIK
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
44
1500000000756
PUSKESMAS MENGANTI
GRESIK
7911360
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
45
1500000000756
PUSKESMAS MENGANTI
GRESIK
7911360
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
46
1500000001490
PUSKESMAS MENTARAS
GRESIK
70954039
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
47
1500000001490
PUSKESMAS MENTARAS
GRESIK
70954039
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
48
1500000001568
PUSKESMAS METATU
GRESIK
7991220
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
49
1500000001568
PUSKESMAS METATU
GRESIK
7991220
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
50
1500000001564
PUSKESMAS NELAYAN
GRESIK
3983036
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
51
1500000001564
PUSKESMAS NELAYAN
GRESIK
3983036
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
280 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
52
1500000001488
PUSKESMAS PANCENG
GRESIK
3940118
DR. JAIMAN
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
53
1500000001488
PUSKESMAS PANCENG
GRESIK
3940118
DR. JAIMAN
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
54
1500000001560
PUSKESMAS SEKAPUK
GRESIK
3948128
DR MUJTAHIDAH
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
55
1500000001560
PUSKESMAS SEKAPUK
GRESIK
3948128
DR MUJTAHIDAH
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
56
1500000001563
PUSKESMAS SEMBAYAT
GRESIK
3949800
DR TITIK ERNA
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
57
1500000001563
PUSKESMAS SEMBAYAT
GRESIK
3949800
DR TITIK ERNA
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
58
1500000001491
PUSKESMAS SIDAYU
GRESIK
3949100
DR WIWIK SUSANTI
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
59
1500000001491
PUSKESMAS SIDAYU
GRESIK
3949100
DR WIWIK SUSANTI
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
60
1500000001567
PUSKESMAS SLEMPIT
GRESIK
7911963
DR. SUKADI
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
61
1500000001567
PUSKESMAS SLEMPIT
GRESIK
7911963
DR. SUKADI
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
62
1500000000175
PUSKESMAS SUKOMULYO
3954818
DR LESTARI
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
63
1500000000175
PUSKESMAS SUKOMULYO
3954818
DR LESTARI
PER/05/012015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
281 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
64
1500000001562
PUSKESMAS UJUNG
PANGKAH GRESIK
3944760
DR SETYORINI
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
65
1500000001562
PUSKESMAS UJUNG
PANGKAH GRESIK
3944760
DR SETYORINI
PER/05/012015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
66
1500000000889
PUSKESMAS WRINGINANOM
GRESIK
8975330
DR BUDI LUHUR
PER/05/012015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
67
1500000000889
PUSKESMAS WRINGINANOM
GRESIK
8975330
DR BUDI LUHUR
PER/05/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
68
1500000000808
331284499
PER/08/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
69
1500000000808
331284499
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
70
1500000000807
331284499
DR RAHMI ZUBAIDAH, SP
MK
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
71
1500000000807
331284499
DR RAHMI ZUBAIDAH, SP
MK
PER/09/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
72
1500000001983
RS FATHMA MEDIKA
61111
3943500
PER/15/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
73
1500000001983
RS FATHMA MEDIKA
61111
3943500
PER/15/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
74
0900000000039
JL JEND A YANI 69
3976688
DR.SINGGIH PRIYANTO,
MARS
PER/02/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
75
0900000000039
JL JEND A YANI 69
3976688
DR.SINGGIH PRIYANTO,
MARS
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
282 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
76
7-140944846
RS SURYA MEDIKA
JL LABAN KULON
61111
031397212
1
DR RAMLI TARIGAN
PER/16/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
77
1500000001993
61174
7914025
RS RAMLI TARIGAN
PER/16/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
78
1500000001993
61174
7914025
RS RAMLI TARIGAN
PER/16/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
79
1500000001519
RS WATES HUSADA
DR TITIN
PER/13/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
80
1500000001519
RS WATES HUSADA
DR TITIN
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
81
1400000000364
RS.MUHAMMADIYAH
GRESIK
JL.KH.KHOLIL NO.88
3981275
DR.MUSA GHUFRON
PER/04/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
82
1400000000364
RS.MUHAMMADIYAH
GRESIK
JL.KH.KHOLIL NO.88
3981275
DR.MUSA GHUFRON
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
83
1400000000363
7406293
DR.HM.FAIZ, SP.THT-KL
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
84
1400000000363
7406293
DR.HM.FAIZ, SP.THT-KL
PER/03/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
85
0900000000002
3951239
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
86
0900000000002
3951239
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
87
7-140917243
JL PENDOPO 45 MANYAR
DR ASLUCHUL
PER/15/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
MA11222I
61151
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
283 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
88
1500000000809
63186435
YUNI HIDAYATI
PER/10/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
89
1500000000809
63186435
YUNI HIDAYATI
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001442
BP ASHABUL KAHFI
8666334
CV KEMBANG TANJUNG
PER/21/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001442
BP ASHABUL KAHFI
8666334
CV KEMBANG TANJUNG
PER/06/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
1500000001442
BP ASHABUL KAHFI
8666334
CV KEMBANG TANJUNG
PER/06/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
1500000001442
BP ASHABUL KAHFI
8666334
CV KEMBANG TANJUNG
PER/06/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
1500000001445
BP HIDAYAH WARU IV
70350252
CV KEMBANG TANJUNG
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
1500000001445
BP HIDAYAH WARU IV
70350252
CV KEMBANG TANJUNG
PER/07/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
1500000001445
BP HIDAYAH WARU IV
70350252
CV KEMBANG TANJUNG
PER/07/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
284 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001445
BP HIDAYAH WARU IV
70350252
CV KEMBANG TANJUNG
PER/07/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
1500000001444
BP KEBANGKITAN
71258886
CV KEMBANG TANJUNG
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
10
1500000001444
BP KEBANGKITAN
71258886
CV KEMBANG TANJUNG
PER/08/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
11
1500000001444
BP KEBANGKITAN
71258886
CV KEMBANG TANJUNG
PER/08/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
12
1500000001444
BP KEBANGKITAN
71258886
CV KEMBANG TANJUNG
PER/08/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
13
1500000001443
BP KESAYANGAN
8700691
CV KEMBANG TANJUNG
PER/09/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
14
1500000001443
BP KESAYANGAN
8700691
CV KEMBANG TANJUNG
PER/09/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
15
1500000001443
BP KESAYANGAN
8700691
CV KEMBANG TANJUNG
PER/20/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
16
1500000001443
BP KESAYANGAN
8700691
CV KEMBANG TANJUNG
PER/09/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
17
1500000001446
BP KESEJAHTERAAN
8706755
CV KEMBANG TANJUNG
PER/10/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
18
1500000001446
BP KESEJAHTERAAN
8706755
CV KEMBANG TANJUNG
PER/19/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
19
1500000001446
BP KESEJAHTERAAN
8706755
CV KEMBANG TANJUNG
PER/10/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
285 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
20
1500000001446
BP KESEJAHTERAAN
8706755
CV KEMBANG TANJUNG
PER/10/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
21
1500000001335
8291214
DR SAID MOHAMMAD T
PER/09/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
22
1500000001335
8291214
DR SAID MOHAMMAD T
PER/15/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
23
1500000001393
5324326
CV KARYA MEDIKA
PER/16/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
24
1500000001393
5324326
CV KARYA MEDIKA
PER/16/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
25
1500000001393
5324326
CV KARYA MEDIKA
PER/16/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
26
1500000001393
5324326
CV KARYA MEDIKA
PER/16/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
27
1500000001394
CV KARYA MEDIKA
PER/17/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
28
1500000001394
CV KARYA MEDIKA
PER/17/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
29
1500000001394
CV KARYA MEDIKA
PER/17/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
30
1500000001394
CV KARYA MEDIKA
PER/17/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
31
1500000001395
JL NGAGLIK NO 47 SURABAYA
CV KARYA MEDIKA
PER/18/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
MA11222I
3764782
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
286 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
32
1500000001395
JL NGAGLIK NO 47 SURABAYA
3764782
CV KARYA MEDIKA
PER/15/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
33
1500000001395
JL NGAGLIK NO 47 SURABAYA
3764782
CV KARYA MEDIKA
PER/18/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
34
1500000001395
JL NGAGLIK NO 47 SURABAYA
3764782
CV KARYA MEDIKA
PER/18/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
35
1500000001379
KLINIK SARTIKA 36
34417343
PER/11/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
36
1500000001379
KLINIK SARTIKA 36
34417343
PER/11/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
37
1500000001379
KLINIK SARTIKA 36
34417343
PER/11/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
38
1500000001379
KLINIK SARTIKA 36
34417343
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
39
1500000001377
KLINIK SARTIKA 44
34200705
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
40
1500000001377
KLINIK SARTIKA 44
34200705
PER/12/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
41
1500000001377
KLINIK SARTIKA 44
34200705
PER/12/012016
RS.TRAUMA
CENTRE
01/02/2016
31/12/2016
42
1500000001377
KLINIK SARTIKA 44
34200705
PER/12/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
43
1500000001376
KLINIK SARTIKA 59
34183507
PER/12/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
287 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
44
1500000001376
KLINIK SARTIKA 59
34183507
PER/13/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
45
1500000001317
KLINIK SARTIKA 77
JL TRUNOJOYO NO 2 SEPANJANG
7871549
PER/08/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
46
1500000001317
KLINIK SARTIKA 77
JL TRUNOJOYO NO 2 SEPANJANG
7871549
PER/14/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
47
N13
POLI SARTIKA 36
5017791
PER/08/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
48
1500000001373
7667983
PER/13/062015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2015
49
1500000001373
7667983
PER/05/012016
RS.TRAUMA
CENTRE
29/01/2016
31/12/2016
50
1500000001373
7667983
PER/05/012016
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
51
1500000001373
7667983
PER/05/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
52
1100000000018
8289668
PT BHAKTI RAHAYU
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
53
1100000000018
8289668
PT BHAKTI RAHAYU
PER/03/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
54
1100000000008
RS BUNDA SURABAYA
7440077
PT PERMATA BUNDA
BERSAMA
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
55
1100000000008
RS BUNDA SURABAYA
7440077
PT PERMATA BUNDA
BERSAMA
PER/02/012015
RS.TRAUMA
CENTRE
04/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
288 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
56
0900000000003
RS MUJI RAHAYU
7404132
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
57
0900000000003
RS MUJI RAHAYU
7404132
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
58
1100000000019
RS WIJAYA (TC)
7523087
YAYASAN WIJAYA
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
59
1400000000385
RS WIYUNG SEJAHTERA
7532653
PT WIYUNG SEJAHTERA
PER/04/012016
RS.TRAUMA
CENTRE
07/01/2016
31/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
1500000000728
3761150
1500000000953
BP PERDANA HUSADA
7403300
1500000001612
BP RAJAWALI 1
JL KREMBANGAN BARAT NO 26 D
34061757
1500000001610
JL KENJERAN NO 189
31362696
1500000000887
MA11222I
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PER/07/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/12/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
DR RR KARTIWI ATMINI
PER/017/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
DR RISTA YULIANA
SUGIANTO
PER/015/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/11/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
HASAN BASRI
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
289 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000891
DINAYLA UTAMA 79
7496347
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
30/06/2016
1500000000888
DINAYLA UTAMA 84
SIMOPOMAHAN 3/14
3136269
PER/10/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001065
PER/13/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000001554
331212060
PER/016/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000000737
5032103
PER/06/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1400000000517
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
12
1400000000517
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
13
1400000000517
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
14
1400000000517
FFS
02/01/2015
31/12/2015
15
0700000000012
RS AL-IRSYAD
3531223
DR AHMAD BAKARMAN,
MARS
PER/ 02/012016
RS.TRAUMA
CENTRE
13/01/2016
31/10/2016
16
0700000000012
RS AL-IRSYAD
3531223
DR AHMAD BAKARMAN,
MARS
PER/ 02/012016
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
17
1500000000726
RS BHAYANGKARA TK. IV
M. DAHLAN
3551043
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
290 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
18
1400000000469
3294801
PT RUMAH SAKIT
PRIMASATYA HUSADA
CITRA
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
19
1400000000469
3294801
PT RUMAH SAKIT
PRIMASATYA HUSADA
CITRA
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001024
1348
1100000000011
1100000000011
1347
1347
1346
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
8419906
SITI MURIYAH
PER/01/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
5954477
NIKEN MADIANINGRUM
1346
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
60293
70932808
PT PRIMA KARYA
BERSAUDARA
PER/01/092015
RS.TRAUMA
CENTRE
21/12/2015
31/12/2015
60293
70932808
PT PRIMA KARYA
BERSAUDARA
PER/01/092015
RS.TRAUMA
CENTRE
28/12/2015
31/12/2016
JL KENDANGSARI GG III NO 20
8483147
NURANI JAYA
1347
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
JL KENDANGSARI GG III NO 20
8483147
NURANI JAYA
1347
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
8473668
KLINIK NURANI
1346
RS.TRAUMA
CENTRE
01/06/2015
01/05/2016
60236
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
291 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000361
60298
71384589
PER/01/102015
RS.TRAUMA
CENTRE
28/12/2015
31/12/2016
1400000000361
60298
71384589
PER/01/10/2015
RS.TRAUMA
CENTRE
21/12/2015
31/12/2015
10
7-804633213
RS ISLAM JEMURSARI
SURABAYA
60236
PER/01/082015
RS.TRAUMA
CENTRE
03/12/2015
31/12/2016
11
1400000000362
RS ISLAM SURABAYA A
YANI
60241
8284505
PER/01/112015
RS.TRAUMA
CENTRE
28/12/2015
31/12/2016
12
1400000000362
RS ISLAM SURABAYA A
YANI
60241
8284505
PER/01/112015
RS.TRAUMA
CENTRE
21/12/2015
31/12/2015
13
1100000000022
RS ISLAM SURABAYA
JEMURSARI
JL JEMURSARI 51-57
60236
847187778
YAYASAN RS ISLAM
SURABAYA
PER/01/082015
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
14
1500000001994
60111
8476111
PER/01/102015
RS.TRAUMA
CENTRE
28/10/2015
27/10/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001639
1500000001640
RSUD PEMANGKAT
MA11222I
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
631798
DR SEMUEL GERITS
RAHANRA, MPH
TIPE IKS
AWAL IKS
AKHIR IKS
PER/04/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/03/03/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
292 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
1400000000227
JL H BOEJASIN NO 68 PELAIHARI
22009
1500000000151
RS KHUSUS BEDAH
BANJARMASIN SIAGA
3267352
1500000000216
1500000000949
1500000000950
TIPE IKS
AWAL IKS
AKHIR IKS
PER/05/042015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/02/022015
RS.TRAUMA
CENTRE
02/02/2015
29/02/2016
6710000
PER/03/022015
RS.TRAUMA
CENTRE
03/02/2015
31/01/2016
21653
PER/09/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
31075
PER/10/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000020
JL JEND. SUDIRMAN NO 10 RT 13 RW 01
MARABAHAN
4799118
PER/15/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000765
RUMAH SAKIT
BHAYANGKARA
BANJARMASIN
3256528
PER/07/052015
RS.TRAUMA
CENTRE
06/05/2015
31/05/2017
1500000001493
3252570
PER/08/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1400000000226
3353335
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
KANTOR CABANG
MA11222I
PT SUTIKSNA
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
293 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001648
PUSKESMAS BAAMANG I
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001650
PUSKESMAS BAAMANG II
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001643
PUSKESMAS BAGENDANG
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001634
PUSKESMAS BAPINANG
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001657
PUSKESMAS CEMPAKA
MULIA
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001645
PUSKESMAS KETAPANG I
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001646
PUSKESMAS KETAPANG II
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001656
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
1500000001661
PUSKESMAS KUALA
KUAYAN
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
10
1500000001654
PUSKESMAS MENTAYA
SEBERANG
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
11
1500000001659
PUSKESMAS PARENGGEAN I
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
12
1500000001660
PUSKESMAS PARENGGEAN
II
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
294 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
13
1500000001653
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
14
1500000001658
PUSKESMAS PUNDU
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
15
1500000001642
PUSKESMAS SAMUDA
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
16
1500000001655
PUSKESMAS SEBABI
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
17
1500000001663
PUSKESMAS TUMBANG
KALANG
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
18
1500000001664
PUSKESMAS TUMBANG
PENYAHUAN
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
19
1500000001662
PUSKESMAS TUMBANG
SANGAI
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
20
1500000001635
PUSKESMAS UJUNG
PANDARAN
PER/02/062015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
21
1400000000145
JL HM ARSYAD NO 65
25052
PEMKAB KOTIM
PER/05/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1400000000146
21017
RSUD KUALA
PEMBUANG
PER/06/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
23
1500000000116
JL SAMPIT-PANGKALANBUN KM 142
PEMBUANG HULU
2033125
PER/04/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
295 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
1400000000374
RSUD H ABDURRAHMAN
NOOR TANAH BUMBU
71067
1500000000845
1500000000845
KANTOR CABANG
NO
KODE PROVIDER
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PER/02/032015
RS.TRAUMA
CENTRE
01/04/2015
28/02/2016
22945
PER/01/012016
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
22945
PER/04/052015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2015
NAMA PROVIDER
ALAMAT
1500000001713
1400000000279
1500000000632
1500000000740
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/11/05/2015
RS.TRAUMA
CENTRE
11/05/2015
11/06/2016
31459
PER/18/082015
RS.TRAUMA
CENTRE
01/08/2015
01/08/2016
49418222
HERIANSYAH
PER/015/042015
RS.TRAUMA
CENTRE
07/04/2015
07/04/2017
3239444
DR.SUYANTO, SP.PD
PER/06/042015
RS.TRAUMA
CENTRE
22/04/2015
22/05/2017
1400000000137
JL PATIANON NO 6 BUNTOK
21021
RSUD BUNTOK
PER/07/042015
RS.TRAUMA
CENTRE
30/04/2015
27/04/2017
1500000001397
31300
PER/14/062015
RS.TRAUMA
CENTRE
11/06/2015
11/06/2017
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
296 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001396
1500000001375
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
2091235
TIPE IKS
AWAL IKS
AKHIR IKS
PER/17/062015
RS.TRAUMA
CENTRE
11/06/2015
11/07/2017
DR. I NYOMAN
INDRAWAN SO.PD
PER/12/052015
RS.TRAUMA
CENTRE
25/05/2015
25/05/2017
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-1706946523
PUSKESMAS KUMAI
74181
DR ABIMAYU
PER/03/012016
RS.TRAUMA
CENTRE
29/01/2016
18/01/2017
7-1702557673
PUSKESMAS SEMANGGANG
74183
DR JHONFERI
SIDABALOK
PER/02/012016
RS.TRAUMA
CENTRE
29/01/2016
18/01/2017
1400000000346
RSUD IMANUDDIN
PANGKALAN BUN
PER/03/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000552
7091900
DR.HADI YUNIARKO
PER/16/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1500000001318
441362
DEBBY TANDY, SE
PER/19/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
297 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
AWAL IKS
AKHIR IKS
PER/02/092015
RS.TRAUMA
CENTRE
21/12/2015
07/09/2016
PER/43/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/46/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001427
PER/41/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001437
PER/31/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001440
PUSKESMAS DAMAI
PER/22/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001450
PUSKESMAS GUNUNG
BAHAGIA
PER/25/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1500000001435
PUSKESMAS GUNUNG
SAMARINDA
PER/33/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
1500000001431
PER/37/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
12
1500000001428
PER/40/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
13
1500000001432
PER/36/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
14
1500000001436
PUSKESMAS KARANG
JOANG
PER/32/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
7-1030679543
1500000001423
1500000001421
MA11222I
76252
I DEWA MADE
SUDARSANA
TIPE IKS
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
298 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
15
1500000001430
PER/38/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1500000001426
PUSKESMAS KARIANGAU
PER/42/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
17
7-1039247964
PUSKESMAS KAYUNGO
76282
I DEWA MADE
SUDARSANA
PER/15/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
18
7-1036615116
PUSKESMAS KERANG
76261
I DEWA MADE
SUDARSANA
PER/04/092015
RS.TRAUMA
CENTRE
23/12/2015
07/09/2016
19
1500000001447
PUSKESMAS KLANDASAN
ILIR
PER/23/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
20
7-1039186643
PUSKESMAS KRAYAN
76282
I DEWA MADE
SUDARSANA
PER/14/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
21
7-1038939360
PUSKESMAS KUARO
76281
I DEWA MADE
SUDARSANA
PER/11/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
22
1500000001441
PUSKESMAS LAMARU
PER/28/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
23
7-1039031521
PUSKESMAS LOLO
76281
I DEWA MADE
SUDARSANA
PER/12/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
24
7-1039093892
76282
I DEWA MADE
SUDARSANA
PER/13/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
25
7-1039387686
76283
I DEWA MADE
SUDARSANA
PER/17/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
26
1500000001451
PUSKESMAS MANGGAR
PER/27/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
299 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
27
1500000001438
PUSKESMAS MANGGAR
BARU
PER/30/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
28
1500000001420
PUSKESMAS MARGASARI
PER/47/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
29
1500000001422
PUSKESMAS MARGO
MULYO
PER/45/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
30
1500000001433
PER/35/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
31
7-1039510453
PUSKESMAS MENDIK
76283
I DEWA MADE
SUDARSANA
PER/18/092015
RS.TRAUMA
CENTRE
17/12/2015
07/09/2016
32
7-1039309985
PUSKESMAS MUARA
KOMAM
76253
I DEWA MADE
SUDARSANA
PER/16/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
33
1500000001434
PER/34/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
34
7-1035423185
PUSKESMAS MUSER
76252
I DEWA MADE
SUDARSANA
PER/03/092015
RS.TRAUMA
CENTRE
23/12/2015
07/09/2016
35
7-1038167538
PUSKESMAS PADANG
PENGRAPAT
76251
I DEWA MADE
SUDARSANA
PER/09/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
36
7-1037831466
PUSKESMAS PASIR
BELENGKONG
76271
I DEWA MADE
SUDARSANA
PER/07/09/2015
RS.TRAUMA
CENTRE
21/12/2015
07/09/2016
37
1500000001448
PUSKESMAS PRAPATAN
PER/24/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
38
1500000001424
PUSKESMAS SEPINGGAN
PER/21/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
300 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
39
1500000001425
PUSKESMAS SIDOMULYO
40
7-1037429485
PUSKESMAS SUATANG
BARU
76271
41
7-1037954297
PUSKESMAS SULILIRAN
BARU
76271
42
1500000001429
43
7-1038866109
PUSKESMAS TANAH
GROGOT
76251
44
7-1036975507
76261
45
1500000001449
46
1500000001439
47
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PER/44/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
I DEWA MADE
SUDARSANA
PER/06/092015
RS.TRAUMA
CENTRE
21/12/2015
07/09/2016
I DEWA MADE
SUDARSANA
PER/08/092015
RS.TRAUMA
CENTRE
21/12/2015
07/09/2016
PER/39/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
I DEWA MADE
SUDARSANA
PER/10/092015
RS.TRAUMA
CENTRE
18/12/2015
07/09/2016
I DEWA MADE
SUDARSANA
PER/05/092015
RS.TRAUMA
CENTRE
21/12/2015
07/09/2016
PER/26/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PUSKESMAS TERITIP
PER/29/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1400000000064
RS BALIKPAPAN BARU
877330
DR M DANARTO, M MED
PER/04/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
48
1400000000045
RS PERTAMINA
BALIKPAPAN
734020
PT PERTAMINA BINA
MEDIKA
PER/02/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
49
1400000000065
427342
PT RESTU IBU
BALIKPAPAN
PER/03/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
50
1500000000729
DRG.DYAH MURYANI
PER/15/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
301 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
51
1500000000184
7211361
DR.JANSJE GRACE
MAKISURAT
PER/10/012015
RS.TRAUMA
CENTRE
05/02/2015
05/02/2016
52
1500000000188
RUMAH SAKIT
BHAYANGKARA
BALIKPAPAN
421261
DR.WILDAN DJAYA
SOEKMARA,SP.B,FINACS
PER/06/012015
RS.TRAUMA
CENTRE
01/02/2015
28/02/2016
53
1500000001325
761141
DR.MARKUS KABAN,
SP.PK
PER/18/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
54
1400000000047
24563
PER/05/022015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
55
1300000000048
SILOAM HOSPITALS
7206509
PER/38/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
56
1500000001034
762681
PER/01/012015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
1500000001816
1500000000915
7-1380214421
PUKESMAS BANTUAS
JL BANTUAS PALARAN
MA11222I
PT BALIKPAPAN DAMAI
HUSADA
KODE
POS
75126
75241
IKS
TELEPON
PIMPINAN
NO IKS
272421
PEMERINTAH
TIPE IKS
AWAL IKS
AKHIR IKS
PER/04/062015
RS.TRAUMA
CENTRE
04/06/2015
04/06/2016
021/K.ST.Y/IV/2
015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
302 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-1464240699
75122
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
7-1464311570
PUSKESMAS BAQA
75131
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
7-1356917662
PUSKESMAS BENGKURING
BENGKURING
75118
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
7-1380408843
PUSKESMAS BUKUAN
JL BUKUAN PALARAN
75241
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
7-1464600433
PUSKESMAS HARAPAN
BARU
75131
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
7-1359826423
PUSKESMAS JUANDA
75122
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
10
7-1507208803
JL KARANG ASAM
75125
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
11
7-1464440551
PUSKESMAS LEMPAKE
75118
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
12
7-1466746238
75125
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
13
7-1380502014
PUSKESMAS MAKROMAN
JL MAKROMAN PALARAN
75241
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
14
7-1464657234
PUSKESMAS
MANGKUPALAS
75131
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
15
7-1464111057
PUSKESMAS PALARAN
JL PALARAN
75241
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
303 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
7-1380304232
PUSKESMAS PASUNDAN
75122
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
17
7-1463967676
PUSKESMAS REMAJA
75117
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
18
7-1464167298
PUSKESMAS SAMBUTAN
JL SAMBUTAN
75114
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
19
7-1461318105
PUSKESMAS SEGIRI
75111
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
20
7-1380543865
PUSKESMAS SEMPAJA
75118
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
21
7-1465607297
PUSKESMAS SIDOMULYO
75114
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
22
7-1464546252
75114
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
20/01/2016
31/12/2016
23
7-1378835889
75118
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
24
7-1380635626
PUSKESMAS TEMINDUNG
75118
PEMERINTAH
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
25
1500000000941
PUSKESMAS TRAUMA
CENTRE
PKS/01/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
26
7-1380777307
PUSKESMAS WONOREJO
KELURAHAN WONOREJO
PKS/02/12.2015
RS.TRAUMA
CENTRE
12/01/2016
31/12/2016
27
1500000001242
RS SAMARINDA MEDIKA
CITRA
PKS/02/04/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
MA11222I
75125
PEMERINTAH
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
304 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
28
1500000000320
29
7-1356184197
KANTOR CABANG
NO
KODE PROVIDER
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
75131
PEMERINTAH
TIPE IKS
AWAL IKS
AKHIR IKS
PKS/01/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
PKS/01/12.2015
RS.TRAUMA
CENTRE
11/01/2016
31/12/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000595
KLINIK CARSA
31457
PER/09/042015
RS.TRAUMA
CENTRE
21/04/2015
20/04/2016
1500000001245
RS PERTAMEDIKA
TARAKAN
31403
RS PERTAMEDIKA
TARAKAN
PER/11/052015
RS.TRAUMA
CENTRE
06/05/2015
05/05/2016
1500000000257
TANJUNG SELOR
PEMKAB BULUNGAN
PER/04/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
1100000000038
RSUD NUNUKAN TC
PEMKAB NUNUKAN
PER/14/082015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
7-582361147
JL P IRIAN NO 1 TARAKAN
PEMPROV KALTIM
PER/13/082015
RS.TRAUMA
CENTRE
30/11/2015
02/08/2016
1100000000037
RSUD TARAKAN TC
JL.P.IRIAN SKIP
PEMPROV KALTIM
0PER/12/07/2015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2015
KANTOR CABANG
MA11222I
24416
00000
21166
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
305 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PT KALTIM MEDIKA
UTAMA
PER/12/052015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2017
PT KALTIM MEDIKA
UTAMA
PER/13/052015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2017
23388
PT KALTIM MEDIKA
UTAMA
PER/14/052015
RS.TRAUMA
CENTRE
27/04/2015
26/04/2017
24555
RUSTAM EFFENDI
PER/16/082015
RS.TRAUMA
CENTRE
28/08/2015
27/08/2016
JL OKSIGEN NO 1
41118
PT KALTIM MEDIKA
UTAMA
PER/08/042015
RS.TRAUMA
CENTRE
20/04/2015
19/04/2017
1400000000234
3036990
PER/09/042015
RS.TRAUMA
CENTRE
24/04/2015
23/04/2016
1500000000932
PER/10/042015
RS.TRAUMA
CENTRE
24/04/2015
23/04/2016
1500000001250
1500000001249
1500000001248
1400000000342
1500000000946
KANTOR CABANG
NO
KODE
POS
KODE PROVIDER
24800
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-1506142935
PUSKESMAS GUNUNG
TABUR
77352
DINAS KESEHATAN
KABUPATEN BERAU
PER/06/122015
RS.TRAUMA
CENTRE
20/01/2016
01/12/2016
7-1507943081
PUSKESMAS KAMPUNG
BUGIS
77311
DINAS KESEHATAN
KABUPATEN BERAU
PER/06/122015
RS.TRAUMA
CENTRE
20/01/2016
01/12/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
306 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-1506142939
PUSKESMAS SAMBALIUNG
77371
DINAS KESEHATAN
KABUPATEN BERAU
PER/06/122015
RS.TRAUMA
CENTRE
20/01/2016
01/12/2016
7-1506142933
77315
DINAS KESEHATAN
KABUPATEN BERAU
PER/06/122015
RS.TRAUMA
CENTRE
20/01/2016
01/12/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000815
891938
CHRISTOPORUS
BUDIONO
16/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1400000000069
21192
PER/04/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1400000000069
21192
PER/04/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1400000000428
PT SILOAM INTERNATIONAL
HOSPITAL MANADO
PER/23/112015
RS.TRAUMA
CENTRE
28/01/2016
31/12/2017
02412
21332
PER/22/10/2015
RS.TRAUMA
CENTRE
28/01/2016
31/12/2017
1400000000066
RS KINAPIT
21192
PER/03/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1400000000068
RS ROBERT WOLTER
MONGISIDI
876087
PER/05/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
307 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000067
RS SITTI MARYAM
851577
PER/02/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
1400000000169
RSUD BOLAANG
MONGONDOW SELATAN
2629444
PER/10/032015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
10
1400000000175
RSUD BOLAANG
MONGONDOW UTARA
085241745
656
DR SUGENG HERMAWAN
PER/11/032015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
11
1400000000059
35030
PER/12/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
12
1500000000352
RUMAH SAKIT
BHAYANGKARA MANADO
PER/01/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
13
1500000000085
LUCI
PER/022/10/2015
RS.TRAUMA
CENTRE
28/01/2016
31/12/2017
14
1500000000816
811077
DR. DIAN
MULYAWARMAN, SP.M
PER/17/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
15
1400000000168
085341986
277
DR EINE CH ESTER
KODONGAN
PER/09/032015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
16
1500000000410
DR BOBBY HAN
INKIRIWANG
PER/13/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
17
1500000000217
DR BLESSING ROMPIS
PER/016/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
18
1500000000227
DR JAWALI JURRY
EKTIVIANUS M.KES
PER/017/022015
RS.TRAUMA
CENTRE
01/02/2015
31/01/2016
KANTOR CABANG
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
308 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
1500000000952
1400000000290
PUSKESMAS SALAKAN
1400000000054
RSD. MADANI
491470
1400000000081
RSU LUWUK
21820
1400000000083
RSU. ANUTAPURA
462770
1400000000440
RSUD AMPANA
1400000000140
RSUD ANUNTALOKO
1400000000438
RSUD BUOL
1400000000231
RSUD KABELOTA
10
1400000000325
RSUD KOLONODALE
11
1400000000118
RSUD MOKOPIDO
12
1400000000324
RSUD MOROWALI
MA11222I
PIMPINAN
3149088
21032
TIPE IKS
AWAL IKS
AKHIR IKS
PER/008/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
DR. JAMES HD
PINONTOAN
PER/16/082015
RS.TRAUMA
CENTRE
14/01/2016
31/07/2016
PER/003/022015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
PER/011/062015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
DR RENNY A
LAMADJIDO, SPPK
PER/004/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
PER/017/082015
RS.TRAUMA
CENTRE
01/11/2015
31/10/2016
PER/010/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/018/082015
RS.TRAUMA
CENTRE
01/11/2015
31/10/2016
PER/007/052015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
PER/013/082015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
PER/019/102015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/014/082015
RS.TRAUMA
CENTRE
01/09/2015
31/08/2016
DRG. HAMZAH
ARIFANDI, M.KES
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
309 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
TIPE IKS
AWAL IKS
AKHIR IKS
31/07/2016
PER/005/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
DR. ABDULLAH
DHSM.M.KES
PER/009/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
PER/020/102015
RS.TRAUMA
CENTRE
01/12/2015
30/11/2016
PER/32/122014
RS.TRAUMA
CENTRE
01/12/2015
30/11/2016
PER/021/102015
RS.TRAUMA
CENTRE
01/12/2015
30/11/2016
14
1500000000735
15
1400000000119
RSUD UNDATA
16
1400000000577
17
1400000000628
RUMAH SAKIT
BHAYANGKARA
18
1400000000588
KODE PROVIDER
NO IKS
01/08/2015
RSUD POSO
NO
PIMPINAN
RS.TRAUMA
CENTRE
1400000000277
IKS
TELEPON
PER/012/072015
13
KANTOR CABANG
KODE
POS
456099
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000879
PUSKESAMAS ASPARAGA
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000908
PUSKESMAS BATUDAA
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000886
PUSKESMAS BATUDAA
PANTAI
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
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310 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000877
PUSKESMAS BILATO
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000906
PUSKESMAS BILUHU
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000883
PUSKESMAS BOLIYOHUTO
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000880
PUSKESMAS BUHU
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000884
PUSKESMAS DUNGALIYO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
1500000000864
PUSKESMAS LIMBOTO
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
10
1500000000870
PUSKESMAS LIMBOTO
BARAT
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1500000000881
PUSKESMAS MOLOPATODU
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
12
1500000000875
PUSKESMAS MOOTILANGO
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
13
1500000000876
PUSKESMAS PILOHAYANGA
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
14
1500000000878
PUSKESMAS PULUBALA
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
15
1500000000885
PUSKESMAS TABONGO
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
311 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
16
1500000000910
PUSKESMAS TELAGA
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
17
1500000000905
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
18
1500000000907
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
19
1500000000904
PUSKESMAS TIBAWA
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
20
1500000000909
PUSKESMAS TILANGO
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
21
1500000000874
PUSKESMAS
TOLANGOHULA
DINAS KESEHATAN
KABUPATEN
GORONTALO
PER/06/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
22
1400000000104
RSUD M.M.DUNDA
PER/03/042015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
23
1400000000477
RSUD OTANAHA
RSUD OTANAHA
PER/10/112014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
24
1400000000102
PER/04/042015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
25
1400000000102
PER/04/042015
RS.TRAUMA
CENTRE
01/01/2016
31/12/2016
26
1400000000103
PER/15/102015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
27
1400000000155
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
881455
8701943
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
312 / 322
09-02-2016
18:49:59
NO
28
KODE PROVIDER
1500000001830
KANTOR CABANG
NO
NAMA PROVIDER
KODE PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
830820
YAYASAN
KESEJAHTERAAN UMAT
HASANAH GORONTALO
PER/04/052015
TIPE IKS
AWAL IKS
RS.TRAUMA
CENTRE
01/05/2015
AKHIR IKS
30/04/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000110
PER/41/122014
RS.TRAUMA
CENTRE
06/01/2015
06/01/2016
1500000000032
PER/41/122014
RS.TRAUMA
CENTRE
06/01/2015
06/01/2016
1400000000117
581983
PROF.DR.DR.HJ.SURYANI
AS'AD M,SC,SP.GK
PER/31/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
07808
KLINIK PAJJAIANG
399696477
RUSMAN,S.SI.APT
PER/37/062015
KAPITASI
01/06/2015
31/05/2016
07678
2940091
PER/36/062015
FFS
01/06/2015
31/05/2016
1400000000075
KLINIK SEROJA
550228
PER/27/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000161
PUSKESMAS BUNGORO
4291557
PER/21/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1400000000170
317343
PER/29/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
313 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000044
454567
PT MAKASSAR GLOBAL
AWAL BROS
PER/25/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
10
1400000000046
RS ISLAM FAISAL
MAKASSAR
871942
PROF DR H SYAFRUDDIN
WAHID PHD,SP,PA(K)
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
11
1500000000332
RS TNI AU DR DODY
SARJOTO
553185
PER/01/032015
RS.TRAUMA
CENTRE
16/03/2015
31/12/2016
12
1500000000333
RSU HIKMAH
JL YOSEF LATUMAHINA NO 1
872284
PER/45/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
13
1400000000190
JL NURUSSAMAWATI NO 9 PAREPARE
21163
PER/23/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
14
1500000000033
JL DG MASEPPE
PER/43/122014
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
15
1400000000171
PER/20/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
16
1400000000345
RSUD LAMADUKELLENG
SENGKANG WAJO
PER/19/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
17
1400000000173
PER/24/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
18
1400000000195
RSUD LATEMMAMALA
PER/30/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
19
1400000000189
RSUD PANGKEP
2311118
PER/02/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
20
1400000000172
RSUD SALEWANGANG
MAROS
371166
PER/28/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
II.DR. H. KAMARUDDIN
SAID, SP.B, MARS
21065
21004
ARMAN
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
314 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
21
1400000000077
5068931
PEMERINTAH PROVINSI
SULAWESI SELATAN
PER/18/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
22
1400000000213
RSUD SINJAI
21132
PER/22/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
23
1500000000480
99257248
PER/14/022015
RS.TRAUMA
CENTRE
14/01/2015
14/01/2016
24
1500000000111
RSUP DR WAHIDIN
SUDIROHUSODO MAKASSAR
JL PERINTIS KEMERDEKAAN KM 11
TAMALANREA
PER/05/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
25
1400000000162
RUMAH SAKIT
BHAYANGKARA MAKASSAR
PER/26/032015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
26
1500000001893
SILOAM HOSPITALS
PER/34/052015
RS.TRAUMA
CENTRE
07/04/2015
06/04/2017
KANTOR CABANG
NO
KODE PROVIDER
836344
90134
KEPOLISIAN NEGARA
REPUBLIK INDONESIA
3662900
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
7-477552713
93114
PER/002/042015
RS.TRAUMA
CENTRE
24/11/2015
31/03/2017
7-477552713
93114
PER/002/042015
RS.TRAUMA
CENTRE
04/12/2015
01/04/2017
1500000000583
PUSKESMAS ABELI
DINAS KESEHATAN
KOTA KENDARI
PER/03/042015
RS.TRAUMA
CENTRE
16/04/2015
15/04/2016
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
315 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000001056
RS TNI AD TK.IV DR R
ISMOYO
PER/04/052015
RS.TRAUMA
CENTRE
25/05/2015
24/05/2016
1400000000062
DINAS KESEHATAN
KOTA KENDARI
PER/004/012016
RS.TRAUMA
CENTRE
05/01/2016
04/02/2017
1500000000526
RUMKIT BHAYANGKARA
KENDARI.
POLDA SULAWESI
TENGGARA
PER/02/042015
RS.TRAUMA
CENTRE
14/04/2015
13/04/2017
KANTOR CABANG
NO
KODE PROVIDER
3121253
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000095
14201909
PAK ASWARDI, DR
SYUKUR
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000001802
342620237
DR ADI SASTRAWIJAYA
PER/11/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000001332
357401801
DR ERICK GAMALIEL
AMBA M.KES SP.OT
PER/10/062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
1500000000097
DR YAIN PANGGALO
JL PONGTIKU RANTEPAO
255009811
DR YAIN PANGGALO
PER/02/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000096
398362717
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000098
PUSKESMAS BUA
342718401
DR BUNADI
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
316 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000049
RS BINTANG LAUT
JL K.H.M. KASIM NO 5
21302
YAYASAN RATNA
MIRIAM
PER/12/032015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
1500000000128
RS HIKMAH
87248801
DR ISWANTO
PER/06/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000838
JL ANDI DJEMMA NO 06
97822888
YAYASAN AT MEDIKA
PER/07/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
10
1500000000868
RSUD LAKIPADADA
PER/09/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
11
1500000000094
081244749
330
PER/05/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
12
1500000000869
JL A. YANI NO 68 RANTEPAO
21258
YAYASAN KESEHATAN
GEREJA TORAJA
PER/08/052015
RS.TRAUMA
CENTRE
01/05/2015
30/04/2016
KANTOR CABANG
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1500000000504
PER/05/022015
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
1500000000100
DR NI PUTU DIAN
SULISTYAWATI, MM (24
JAM)
DR NI PUTU DIAN
SULISTYAWATI, MM
PER/01/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
1500000000139
KLINIK ANUGERAH
JL NANGKA NO 87 A DENPASAR
PER/03/012015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
MA11222I
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
317 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
1500000000078
246701
1500000000451
RS BHAYANGKARA TRIJATA
JL TRIJATA NO 32
222908
1500000000453
1500000001931
80111
1500000001933
RS KASIH IBU
KEDONGANAN
1500000001932
10
1400000000484
RS SURYA HUSADHA
DENPASAR
11
1400000000483
RS SURYA HUSADHA
UBUNG
JL COKROAMINOTO NO 356
12
1200000000017
430270
13
1200000000017
430270
14
1400000000554
32701
15
7-204036033
MA11222I
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PER/19/122014
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
POLRI
PER / 06 /
022015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2017
PER/09/032015
RS.TRAUMA
CENTRE
01/04/2015
31/12/2016
3003030
PER/19/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2016
80351
703270
PER/21/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2016
82111
5003737
PER/20/082015
RS.TRAUMA
CENTRE
01/08/2015
31/12/2016
233787
PER/02/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
PER/01/2016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
PER/05/012016
RS.TRAUMA
CENTRE
05/01/2016
31/12/2016
PER/12/112014
RS.TRAUMA
CENTRE
01/01/2015
31/10/2015
PER/06/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
PER/31/102015
RS.TRAUMA
CENTRE
06/11/2015
31/12/2016
80232
036122201
3
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
318 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
16
1500000000140
94554
17
1400000000482
766154
18
1500000000653
RSU TABANAN
811027
19
1500000000655
RSUD BADUNG
20
1500000000654
RSUD WANGAYA
21
1400000000485
KANTOR CABANG
NO
KODE PROVIDER
PT MEKAR SHANTI
GRAHA
TIPE IKS
AWAL IKS
AKHIR IKS
PER/02/012015
RS.TRAUMA
CENTRE
01/02/2015
31/12/2015
PER/03/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
DR I NYOMAN SUSILA,
M.KES
PER/13/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2016
9006812
PER/15/042015
RS.TRAUMA
CENTRE
01/06/2015
31/12/2016
222141
DR. SETIAWATI
HARTAWAN,M.KES
PER/14/042015
RS.TRAUMA
CENTRE
01/05/2015
31/12/2016
779900
PER/04/012016
RS.TRAUMA
CENTRE
08/01/2016
31/12/2016
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
1100000000003
PROF DR WZ JOHANNES
KUPANG
JL M HOTTA NO 19
1400000000288
RS BHAYANGKARA
KUPANG
JL NANGKA 84 KUPANG
85111
821999
1400000000288
RS BHAYANGKARA
KUPANG
JL NANGKA 84 KUPANG
85111
821999
MA11222I
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PER/ 002/
012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PER/ 017/
102015
RS.TRAUMA
CENTRE
22/01/2016
31/12/2016
PER/ 017/
102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
319 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
PT KARTINI MEDIKAL
KUPANG
PER/ 018
/102015
RS.TRAUMA
CENTRE
04/11/2015
30/09/2016
TNI AL
PER/15/ 062015
RS.TRAUMA
CENTRE
01/06/2015
31/05/2016
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
1400000000417
RSUD DR TC HILLERS
MAUMERE
PER/ 005/
012016
RS.TRAUMA
CENTRE
28/01/2016
31/12/2016
1500000000064
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
10
1500000000582
PER/ 010 /
042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
11
1400000000565
PER/ 003/
012016
RS.TRAUMA
CENTRE
28/01/2016
31/12/2016
12
1400000000418
RSUD NAIBONAT
KABUPATEN KUPANG
85223
PER/ 019/
102015
RS.TRAUMA
CENTRE
01/11/2015
13
1400000000418
RSUD NAIBONAT
KABUPATEN KUPANG
85223
PER/ 019/
102015
RS.TRAUMA
CENTRE
17/12/2015
31/10/2016
14
1500000000394
PER/07/032015
RS.TRAUMA
CENTRE
01/03/2015
28/02/2016
15
1400000000394
PER/ 007/
012016
RS.TRAUMA
CENTRE
01/02/2016
30/01/2017
7-170855890
1400000000090
1500000000469
1500000000470
MA11222I
85112
085242475
035
2426133
21016
61302
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
320 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
16
1500000001987
17
1500000000119
3838123
18
1500000000119
3838123
19
1400000000543
20
7-1708103837
SILOAM HOSPITALS
LABUAN BAJO
21
1500000000438
KANTOR CABANG
NO
KODE PROVIDER
AWAL IKS
AKHIR IKS
PER / 018
/102015
RS.TRAUMA
CENTRE
01/10/2015
30/09/2016
TNI AU
PER/ 004/
012016
RS.TRAUMA
CENTRE
28/01/2016
31/12/2016
TNI AU
PER/04/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
RS.TRAUMA
CENTRE
09/02/2016
09/02/2017
PER/ 006/
012016
RS.TRAUMA
CENTRE
29/01/2016
29/01/2017
RS.TRAUMA
CENTRE
01/03/2015
29/02/2016
85141
86754
TIPE IKS
833270
NAMA PROVIDER
ALAMAT
1500000000500
BLK MATARAM
1400000000390
RS BHAYANGKARA
MATARAM
1400000000429
RS HARAPAN KELUARGA
MA11222I
PIMPINAN
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
623443
/464/NAKERTR
ANS/III/2015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
83117
629149
PER/19/102015
RS.TRAUMA
CENTRE
03/12/2015
31/12/2016
83117
6177000
DR JEFFRY SUGIANTO
PER/20/112015
RS.TRAUMA
CENTRE
03/12/2015
31/12/2016
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
321 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000276
621345
PER/17/082015
RS.TRAUMA
CENTRE
03/12/2015
31/12/2015
1500000000061
RSUD KABUPATEN
SUMBAWA BARAT
8281057
DR HJ DWIWIDIA
MERTASARI
PER/02/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
1400000000111
PER/04/012015
RS.TRAUMA
CENTRE
02/01/2015
31/12/2015
1400000000110
RSUD SUMBAWA
RSUD SUMBAWA
PER/03/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
KANTOR CABANG
NO
KODE PROVIDER
21929
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
NO IKS
1500000000842
8421188
1500000000114
41909
1500000000114
41909
1400000000453
RSUD BANGLI
1400000000395
RSUD KARANGASEM
MA11222I
PIMPINAN
TIPE IKS
AWAL IKS
AKHIR IKS
PER/1001/03201
5
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
PER/009/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
PER/006/012016
RS.TRAUMA
CENTRE
22/01/2016
31/12/2016
91002
PER/006/112015
RS.TRAUMA
CENTRE
16/12/2015
31/12/2016
21470
PER/005/102015
RS.TRAUMA
CENTRE
01/10/2015
31/12/2015
SM0480
Halaman :
Tanggal Cetak :
Waktu Cetak :
322 / 322
09-02-2016
18:49:59
NO
KODE PROVIDER
NAMA PROVIDER
ALAMAT
KODE
POS
IKS
TELEPON
PIMPINAN
NO IKS
TIPE IKS
AWAL IKS
AKHIR IKS
1400000000473
RSUD KLUNGKUNG
21172
PER/005/012016
RS.TRAUMA
CENTRE
22/01/2016
31/12/2016
1400000000321
943049
PER/004/092015
RS.TRAUMA
CENTRE
01/09/2015
31/12/2015
1400000000321
943049
ADD/004/082015
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
1400000000321
943049
PER/003/012016
RS.TRAUMA
CENTRE
22/01/2016
31/12/2017
10
1500000000724
976508
PER/010/042015
RS.TRAUMA
CENTRE
01/04/2015
31/03/2016
11
7-463005405
DR. I NENGAH
SURANTEN
PER/005/112015
RS.TRAUMA
CENTRE
19/11/2015
31/12/2016
12
1200000000003
JL RAYA CELUK,SUKAWATI
298233
PER/002/012016
RS.TRAUMA
CENTRE
18/01/2016
31/12/2016
13
1200000000003
JL RAYA CELUK,SUKAWATI
298233
PER/002/012015
RS.TRAUMA
CENTRE
01/01/2015
31/12/2015
14
1400000000256
41378
DR NI WAYAN PUTU
SUATI
PER/003/072015
RS.TRAUMA
CENTRE
01/07/2015
30/06/2016
MA11222I
80811
SM0480