No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
BALI
BANGLI
001 4898 RS. BANGLI MEDIKA CANTIJL. TIRTA GIRI KUTRI LCSUBAK AYA BEBALANG, BANGLI,
BALI0366-91555/93444| - Y Y ALL COVERAGE
BULELENG
002 1451 RSU. PARAMASIDHI JL. A.YANI NO.171A 0362-29787, 32701,22426,| 0362-29787 Y Y ALL COVERAGE
003 3422 LAB. PRODIA SINGARAJA JL. NGURAH RAI NO. 67 SINGARAJA 0362-24516| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
004 0870 RSU. KERTHA USADA JL. CENDRAWASIH, NO.5-7, SINGARAJA 0362-26277/8| 0362-22741 Y Y ALL COVERAGE
DENPASAR
005 2602 KLINIK & APOTEK KF 108 JL. T.UMAR 246, DENPASAR 0361 245768| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
006 2600 KLINIK & APOTEK KF 236 JL. DANAU BATUR RAYA, TM GRIYA, JIMBARAN 0361 8479785| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
007 1825 LAB. PRODIA WIDYA HUSADHA JL. DIPONEGORO NO. 192 DENPASAR (0361) 261001| (0361) 236349 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
008 1245 RSU. SURYA HUSADHA UBUNG JL. COKROAMINOTO, NO.356, DENPASAR 0361-425744| 0361-430557 Y Y ALL COVERAGE
009 1202 KLINIK MERDEKA MEDICAL CENTER (MMC) MERDEKA VIII/2 TANJUNG BUNGKAK-DENPASAR 0361-233790| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
010 1273 RS. SURYA HUSADHA JL. PULAU SERANGAN,NO.7, DENPASAR 0361-233787| 0361-231177 Y Y ALL COVERAGE
011 1309 BALI ROYAL HOSPITAL ( BROS ) JL. TANTULAR NO 6 RENON DENPASAR 0361- 247499/222588| 0361-226051/226052 Y Y ALL COVERAGE
012 1146 RS. BHAKTI RAHAYU DENPASAR JL. GATOT SUBROTO II, NO.110361-430270 / 430245 / 428287 /
7420673|0361-263371 Y Y ALL COVERAGE
013 1463 KLINIK PENTA MEDIKA JL. TEUKU UMAR BARAT-MARLBORO,NO.88 0361-7446144/490709| 0361 - 490708 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
014 0220 RS. PRIMA MEDIKA JL. PULAU SERANGAN, 9X 0361 - 236225/257445/235318| 0361-236203/262535 Y Y ALL COVERAGE
015 0179 RSU. KASIH IBU DENPASAR JL. TEUKU UMAR, NO.1200361-
223036/3003030/082146806677|0361-238690 Y Y ALL COVERAGE
016 0140 RS. MANUABA JL. HOS. COKROAMINOTO, NO.28 0361-426393| 0361-285183/429447 Y Y ALL COVERAGE
017 0221 RS. PURI RAHARJA JL. WR.SUPRATMAN, NO.14-19, DENPASAR 0361-222013| 0361-242537 Y Y ALL COVERAGE
018 0867 KLINIK&APOTEK KF 34 DENPASAR JL. DIPONEGORO NO.125, DENPASAR 0361-255914-|- 0361-255914 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
019 1047 RS. BALIMED (d/h RS BALI MEDISTRA) JL. MAHENDRADATTA, NO.57X, DENPASAR0361-484748, 482281,8450771,
8450772|0361-8450773,8450770 Y Y ALL COVERAGE
020 1147 RS. DHARMA YADNYA JL. WR.SUPRATMAN NO. 256, TOHPATI 0361-462488 / 462629| 0361-464526Y Y
ALL COVERAGE
021 1150 RSIA. PURI BUNDA JL. GATOT SUBROTO VI, NO.19 0361-437999| 0361-433988 Y Y ALL COVERAGE
022 1151 KLINIK QUANTUM SARANA MEDIK JL. RAYA SESETAN, NO.20 0361-228835| 0361-245274 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
023 3455 APOTIK KIMIA FARMA NO.66 PATIMURA JL. PATIMURA NO.59 DENPASAR 0361-234797| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
024 2599 KLINIK & APOTEK KF 82 JL. KARTIKA PLAZA, NO.67, KUTA-BALI 0361 757196| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
025 4438 KLINIK UTAMA DHARMA SIDHIJL. SERMA KAWI NO. 13-17, DAUH PURI KELOD,
DENPASAR BARAT(0361) 242717; 241013| 361241013 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
026 2598 KLINIK & APOTEK KF 232 JL. RAYA KEROBOKAN 140, SEMINYAK, KUTA 0361 736163| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
GIANYAR
027 1761 RS. ARI CANTI GIANYAR JL. RAYA MAS UBUD GIANYAR 0361-974573| 0361-974573 Y Y ALL COVERAGE
028 3549 RSU. SANJIWANI GIANYAR JL. CIUNG WANARA N0.2 GIANYAR 0361-943049/0361-943020| Y Y ALL COVERAGE
029 4666 RS. FAMILI HUSADAJL. ASTINA TIMUR, SAMPLANGAN, KEC.GIANYAR, KAB.
GIANYAR(0361) 849 3344| (0361) 8493040 Y Y ALL COVERAGE
030 4834 RS. KASIH IBU SABA GIANYAR JL. RAYA PANTAI SABA NO 9 DESA SABA, GIANYAR BALI 0361) 3003333| - Y Y ALL COVERAGE
031 4075 RSU. PREMAGANAJL. HAYANG SANGSI NO.2 PERUM CHANDRA AYU, BANJAR
TUBUH, BATU BULAN - SUKAWATI
0361-8461955/ 296389 /
082144049401|0361-295246 Y Y ALL COVERAGE
JEMBRANA
032 3558 RSU. BUNDA NEGARA JL. RAJAWALI NO. 36, PENDEM, 0365-40251 / 087863229569| 0365-40089 Y Y ALL COVERAGE
KARANGASEM
033 2301 KLINIK PENTA MEDICA CANDIDASA JL. RAYA MANGGIS NO. 88, KAB. KARANGASEM, BALI 0363-41909| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
034 4252 RS. BALIMED KARANGASEM JL. NENAS KECICANG BEBANDEM, KARANGASEM, BALI (0363) 4301618| Y Y ALL COVERAGE
KUTA
035 1138 RSU. KASIH IBU KEDONGANAN JL. ULUWATU, NO.69A, KEDONGANAN 0361-703270| 0361-703329 Y Y ALL COVERAGE
036 1492 KLINIK KASIH IBU KOMPLEKS PERUM BUMI DALUNG PERMAI, BLOK C1-C4 0361-422150/3700616| 0361-422179 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
037 1909 SILOAM HOSPITALS BALI JL. SUNSET ROAD NO. 818, KUTA 0361-779900| 0361-779933 Y Y ALL COVERAGE
NUSA DUA
038 1359 RSU. SURYA HUSADHA NUSA DUA JL. SILIGITA, BLOK 1, NO.14 0361-775827| 0361-771388 Y Y ALL COVERAGE
039 2603 KLINIK & APOTEK KF 126 JL. BY PASS NGURAH RAI NO 890,NUSA DUA 0361 778555| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
040 0222 KLINIK PRIMA MEDIKA JL. BY PASS NGURAH RAI, PERTOKOAN NIAGA, NO.81 0361-770509| 0361-770509 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SANUR
041 1248 KLINIK REMEDIUM CARE JL. BY PASS NGURAH RAI NO.243 0361-288860| 0361-287970 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
042 2604 KLINIK & APOTEK KF 173 JL. BY PASS NGURAHRAI 232,SANUR 0361 283395| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TABANAN
043 3456APOTIK & KLINIK KIMIA FARMA.102
TABANANJL. NGURAH RAI NO.74 A TABANAN 0361-810524| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
044 1714 RS. WISMA PRASANTI JL. YAH GANGGA NO. 9 TABANAN , BALI 0361-8043219/810555| 0361-812454 Y Y ALL COVERAGE
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
Page 1 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
045 2133 RSU. KASIH IBU TABANAN JL. FLAMBOYAN NO. 9 ( KAMPUNG KODOK ) 0361-3005757| 0361-3005758 Y Y ALL COVERAGE
046 4520 PRODIA TABANAN JL. NGURAH RAI NO. 43 KEDIRI TABANAN 0361-812758| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
UBUD
047 0224 UBUD CLINIC JL. TJAMPUHAN, NO.36, P.O.BOX 10, UBUD, GIANYAR 0361-974911| 0361-974910 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BANGKA BELITUNG
BANGKA INDUK
048 2148 RS. ARSANIJL. RAYA AIR KENANGA KEC. SUNGAI LIAT KAB. BANGKA
BLITUNG0717-4297825, 4297834| 0717-4297824 Y Y ALL COVERAGE
BELITUNG
049 2370 RS. ALMAH TANJUNG PANDAN JL. JEND. SUDIRMAN KM. 11 NO. 1 KODE POS 33144 0719-9225666| 0719-9225333 Y Y ALL COVERAGE
050 4842 RS. UTAMA TANJUNG PANDAN
JL. JENDERAL SUDIRMAN KM. 3 RT.019 RW. 008 KEL.
DESA LESUNG BATANG, KEC. TANJUNG PANDAN, KAB.
BELITUNG
0719-9222211| 0719-9222212 Y Y ALL COVERAGE
051 1928 KLINIK UTAMA BELITUNG JL. MERDEKA NO. 27 TANJUNGPANDAN BELITUNG 0719-25526| 71925600 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
052 4769 KLINIK BAKTI TIMAH TANJUNG PANDAN JL. MELATI NO. 32 TANJUNG PENDAM 33416 0719-21865| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PANGKAL PINANG
053 1443 RS. KHATOLIK BHAKTI WARA JL. SUNGAI SELAN, KM.4, NO.180 0717-422605| 0717-424314 Y Y ALL COVERAGE
054 1508 RS. MEDIKA STANNIA JL. JEND.SUDIRMAN, NO.3, SUNGAI LIAT 0717-95837/93335| 0717-953335 Y Y ALL COVERAGE
055 1230 RS. BAKTI TIMAH PANGKAL PINANG JL. BUKIT BARU NO.1 PANGKAL PINANG 0717-421091| 0717-424212 Y Y ALL COVERAGE
056 5063 PRODIA PANGKAL PINANGJL. KH. ABDURRAHMAN SIDDIQ NO. 176, PANGKAL
PINANG0717-438232| - N Y GP,LAB,PHAR
057 0900 SUN CLINIC EL-JOHN PLAZA, JL. SUKARNO HATTA, NO.208 0717-4297888-|- 0717-439488 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
058 2605 KLINIK & APOTEK KF 118 JL. A.YANI, P.PINANG 0717 436762| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
059 5045 RSIA. MUHAYAJL. JEND SUDIRMAN NO. 18, TAMAN BUNGA,
GERUNGGANG, KEP BANGKA BLITUNG0717-436997| Y Y ALL COVERAGE
BANTEN
CILEGON
060 2780 KLINIK GRIYA SEHATPERUMAHAN GRIYA CILEGON BLOK D6-7 KEL.WARINGIN
KURUNGI, KEC.KRAMATWATU 421610254-388501| 0254-388501 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
061 1403 KLINIK KELUARGA PULO AMPEL JL. SALIRA INDAH DS.SUMURANJA PULOAMPEL 0254-5751100 / 0254 - 572100| 0254-5751100 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
062 2389 KLINIK & RB CIGADING MEDIKAJL. RAYA ANYER KM.7 KUBANGSARI CIWANDAN CILEGON
BANTEN0254-311323| 0254-310568 Y Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
063 3158 KLINIK KELUARGA SURALAYA JL. CIRATA NOM 12 KOMPLEK PLTU SURALAYA (0254) 572100| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
064 4327 KLINIK ISNA MEDIKAJL. RAYA MERAK KM.8 KESERANGAN KEL. RAWA ARUM
KEC. GROGOL, CILEGON, BANTEN0254-573756| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
065 3156 LAB. PRODIA CILEGONJL. SULTAN AGENG TIRTAYASA NO. 8, CILEGON - BANTEN
424140254-381990/398969| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
066 1254 RB & KLINIK AFINA JL. RAMBUTAN 12, PAGEBANGAN - CILEGON 0254-392568| 0254-392568 Y Y ALL COVERAGE
067 1536 KLINIK & APOTIK KOTA BAJA JL. S.A. TIRTAYASA, NO.115 0254-391822| 0254-392346/391822 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
068 1298 KLINIK IKHLAS MEDIKA IV PONDOK CILEGON INDAH ( PCI ) BLOK A 19/10 CILEGON 0254-7061935| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
069 1713KLINIK & APOTEK KF 268 PCI CILEGON
(GROUP 140)
PONDOK CILEGON INDAH BLOK A4 NO.01CILEGON -
BANTEN0254-394827| 0254-376501 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
070 1815 KLINIK INSAN PRIMA RUKO CILEGON CITY SQUARE BLOK I-8, CILEGON 0254-393 197| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
071 1943 KLINIK MUTIARA BUNDA JL. S.A TIRTAYASA NO. 86, CILEGON 0254-399968| 0254-399989/376454 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
072 0302 KLINIK ANANDA CILEGON JL. R. SUPRAPTO KM.8 0254-310609| 0254-310821 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
073 0320 KLINIK BONA MEDIKA FESTIVAL RUKO, BLOK B10-11, BONAKARTA 0254-387684| 0254-386699 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
074 0595APOTIK & KLINIK ANNISA SEHAT(D/H PRIMA
HUSADA)
RUKO CILEGON CITY SQUARE ( SAMPING GIANT-PCI)
BLOK B3;5 E3;5
0254 - 399933/3998560254 -
391677|0254 - 3916770254-399928 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
075 0129 APOTIK LABORA FARMA JL. ALUN-ALUN UTARA, NO.23 0254-391695| 0254-374278 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
076 0121 KLINIK AMALIA JL. S.A TIRTAYASA NO.7 0254-391307-|- 0254-391307 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
077 0939 RSIA. MUTIARA BUNDA CILEGONJL. SA TIRTAYASA RUKO MAISONETTE BLOK B 1-2
SIMPANG TIGA CILEGON0254- 399988/376888/399968-|- 0254-376454 Y Y ALL COVERAGE
078 0915 RS. KRAKATAU MEDIKA JL. SEMANG RAYA - CILEGON0254-396333; 0254-372180; 0254-
372123|0254-3721230254-391972/374010 Y Y ALL COVERAGE
079 0951 KLINIK & APOTEK KF 140 JL. S.A. TIRTAYASA NO 12 0254-392278-|- 0254-399173 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
080 0985 RS. KURNIA CILEGON JL. JOMBANG MASJID NO.4 CILEGON 0254-391161|- 0254-396489,397023 Y Y ALL COVERAGE
PANDEGLANG
081 1764 KLINIK ALFURQONJL. RAYA LABUAN KM 2 TOROGONG MARGASANA -
PANDEGLANG0253-5808100| 0253-501313 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
082 0997 KLINIK DIFFA JL. RAYA LABUAN KM.12 CIPUTRI MENES 0253-502161-|- 0253-502160 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
RANGKASBITUNG
083 0658 KLINIK SEHAT RABINZA JL. HADIWINANGUN, PERTOKOAN RABINZA, BLOK B1-2 0252-280023| 0252-280023 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
084 1084 RS. MISI LEBAK JL. MULTATULI NO.41 0252-201014-|- 0252-203390 Y Y ALL COVERAGE
085 3141 KLINIK DAN APOTEK MEDIKA JL. AHMAD YANI RANCASEMA - RANGKASBITUNG 0252-209975| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SERANG
086 0937 KLINIK MODERN MEDIKA CIKANDE JL. RAYA SERANG KM.68 RUKO B6 CIKANDE SERANG 0254-400554-|- 0254-400556 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
087 1004 KLINIK WISATA MEDIKA JL. RAYA ANYER NO.90254-600933/605141/
081905180805-|-0254-605141 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 2 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
088 0115 KLINIK SERANG MEDIKAJL. RAYA SERANG CILEGON RUKO LEGOK SUKMAJAYA
BLOK 5C NO.10254-223992| 0254-223992 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
089 2392 KLINIK & APOTIK BONA SERANGJL. RAYA SERANG - CILEGON RUKO LEGOK SUKMAJAYA
NO. 5A1 SERANG0254-228005/ 287684| 0254-205906 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
090 2608KLINIK & APOTEK KF 472 SERANG BARU
(GROUP 140)JL. AHMAD YANI NO. 57,SERANG 0254 211065| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
091 2726 KLINIK & APOTEK KF 253 (GROUP 140) JL. YUSUF MARTADILAGA NO. 114 SERANG- BANTEN 0254-211447| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
092 4236 KLINIK ALTISJL. RAYA CILEGON KM.2 SABRNG RT.01/05, SERDANG
KEC. KRAMATWATU, SERANG(0254) 386325| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
093 2414 KLINIK JANNAHJL. KH.ABDUL HADI NO.13 KEBUN JAHE SERANG,
KAB.BANTEN0254-209321| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
094 1126 KLINIK KRAKATAU MEDIKA SERANGJL. TB SUWANDI, KAV KEMUNING NO. 1 LINGKAR SELATAN
KEC SERANG0254-204407| 0254-221397 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
095 1414 RSIA. PURI GARCIAJL. GRIYA PURNAMA NO 99 TEGAL PADANG LEGOK,
SERANG BANTEN 421620254-223333| 0254-223786; Y Y ALL COVERAGE
096 1272 RS. SARI ASIH SERANG JL. JEND.SUDIRMAN, NO.38, PENANCANGAN, CIPOCOK 0254-220022| 0254-220345 Y Y ALL COVERAGE
097 1489RS. HERMINA CIRUAS (D/H RS. CITRA
MEDIKA CIRUASJL. RAYA SERANG KM.9 DS.RANJENG - CIRUAS 0254-281829/ 0254-280555| 0254-281845 Y Y ALL COVERAGE
098 2413 KLINIK ANDRI MEDISTRAJL. N. RAYA SERANG JAKARTA KM 8 CIRUAS, SERANG -
BANTEN-| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
099 5285 RSIA. PERMATA SERDANG
JALAN WARINGIN KURUNG RT 001/003 DESA SERDANG,
KECAMATAN KRAMATWATU KABUPATEN SERANG, BANTEN
42161
0254- 387515| 0254-387494 Y Y ALL COVERAGE
100 0716 RS. BUDI ASIH JL. K.H. SOHARI, NO.39 0254-212484/218666| 0254-208583 Y Y ALL COVERAGE
101 0984 KLINIK CIJAWA MEDIKA JL. KH. A. FATAH HASAN NO.8 0254-204735 / 08128521336-|- 0254-204735 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
102 3993 RS. KURNIA SERANGJL. RAYA CILEGON KM.8, DESA KRAMATWATU SERANG -
BANTEN0254-232648| 0254-8235050 Y Y ALL COVERAGE
103 3985 KLINIK & APOTEK MURASAKI MEDIKAKOMP.PEJATEN MAS BLOK C/1 PEJATEN KEC.WATU-
BANTEN0254233317| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
104 1009 KLINIK IKHLAS MEDIKA 2 JL. RAYA SERANG - JAKARTA (DEPAN KAMPUS UNTIRTA) 0254-284937-|- - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
105 1008 KLINIK IKHLAS MEDIKA 1 KOMPLEK BUMI AGUNG PERMAI 1,NO. DI/6 0254-207918-|- 0254-281676 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
106 0941 KLINIK MODERN MEDIKA KRAGILAN JL. RAYA SERANG KM15 RUKO D9 KRAGILAN 0254-281720-|- 0254-281720 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TANGERANG
107 0412RS. PREMIER BINTARO (d/h
RS.INTERNASIONAL BINTARO)JL. MH THAMRIN NO.1, SEKTOR 7, BINTARO JAYA 021-745 5500/27625500| 021-748 64854/745 58 Y Y ALL COVERAGE
108 1637 RS. MULIA INSANI JL. RAYA SERANG KM 16.8 CIKUPA TANGERANG 021-5962790/5962998/5962996| 021-5963099 Y Y ALL COVERAGE
109 1487 RS. MULYA JL. KH.HASYIM ASHARI NO.18 SUDIMARA PINANG 021-7322443; 7322445| 021-7310721/7322445 Y Y ALL COVERAGE
110 1659 RS. HERMINA CIPUTAT JL. CIPUTAT RAYA, NO.2 KERTAMUKTI CIPUTAT 021-74702525/30492525/30492524| 021-74700999 Y Y ALL COVERAGE
111 1669 RSIA. BUAH HATI CIPUTATJL. ARIA PUTRA NO 399 SERUA INDAH CIPUTAT -
TANGERANG021-74632222| 021-74638568 Y Y ALL COVERAGE
112 1670 CIPUTRA HOSPITALJL. CITRA RAYA BOULEVARD BLOK V 00/08 SEKTOR 3,4
KEC PANONGAN021-59405555| 021-59405678 Y Y ALL COVERAGE
113 1812 SMILE N SHINE DENTAL CARE CENTERALAM SUTERA TOWN CENTER (ASTC) BLOK 10D NO 6
TANGERANG021-96679191| 021-29008540 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
114 1866 KLINIK SATELIT GSM BINTARORUKO ELANG RAYA KAV. 1 NO 10-11 JL. BINTARO JAYA
SEKTOR IX021-7450818| 021-7450642 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
115 1867 KLINIK SATELIT GSO CENGKARENGBANDARA INTERNASIONAL SOEKARNO HATTA
CENGKARENG, TANGERANG021-5501801| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
116 0308 PAMULANG MEDICAL CENTER JL. RAYA PAMULANG BLOK D II/2, PAMULANG 021-740 5317| 021-7497624/7429156 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
117 0610 RSIA. PUTRA DALIMAGRIYA LOKA, SEKTOR 1.2, BLOK UA/26-27, BUMI
SERPONG DAMAI
021-5380375/5388279021-5388279
/ 53741|021-5388279 / 53741021-5381220 Y Y ALL COVERAGE
118 0007 RS. UIN SYARIF HIDAYATULLAH JL. IR. H. JUANDA, NO.95, CIPUTAT 021-7402718/7499129| 021-7493532 Y Y ALL COVERAGE
119 0062 KLINIK SARANA MEDIKA BARUJL. RAYA PERUMAHAN KOTA BUMI KP.TERITI
DS.KARET.SEPATAN021-5921153 / 02159372781| 021-59308529 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
120 0291 RS. ICHSAN MEDICAL CENTER (IMC)JL. RAYA JOMBANG NO.56 BINTARO SEKTOR IX,
TANGERANG
021-7456379/ 021-7456386|021-
7456386021-7450819 Y Y ALL COVERAGE
121 0696 KLINIK DOKTER KELUARGA MAWAR JL. KARET RAYA, BLOK 7/69, PERUMNAS TANGERANG021-5525633; 021-5913616|021-
5913616021-5913616 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
122 0344 RS. QADR KOMPLEK ISLAMIC VILLAGE, KELAPA DUA 021-546 4466; 5463107; 5463106| 021-547 0775 Y Y ALL COVERAGE
123 0064RB & KLINIK 24 JAM DIANA PERMATA
MEDIKAJL. MH. THAMRIN, NO.87C
021-5397314/ 53124105021-
5395312|021-5395312021-5394105/5312410 N Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
124 0337 RS. BHINEKA BAKTI HUSADA JL. CABE RAYA NO.17 PONDOK CABE PAMULANG 021-7490018/7490829| 021-7403535 Y Y ALL COVERAGE
125 0902 RB & KLINIK BUNDA MULYA (H UPEN) JL. SUMANTRI NO. 11 MEKAR MULYA PARUNG PANJANG 021-5978058-|- 021-5978058 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
126 0912 KLINIK KARUNIA SEHATRUKO CIKUPA BLOK B NO.21-23, DEPAN PERUM CITRA
RAYA- CIKUPA021-5963001-|- 021- 59408388 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
127 0702 KLINIK MAHARANIBOROBUDUR RAYA NO 152 PERUMNAS II BENCONGAN
KELAPA DUA, TANGERANG021-55654096; 5919953| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
128 0285 RS. MELATI JL. MERDEKA, NO.92 021-5523945/55776739| 021-55769914/5520028 Y Y ALL COVERAGE
129 0108 KLINIK PROVITA JL. IR.H.JUANDA NO.125 CIPUTAT 021-749 2619| 021-744 0085 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
130 0091 MAYAPADA HOSPITAL (D/H RS. HONORIS) JL. HONORIS RAYA, KAV.6, KOTA MODERN/KODYA DATI II 021-5529035/55781999| 021-5529465/5529036 Y Y ALL COVERAGE
131 0022 RS. SARI ASIH KARAWACI JL. IMAM BONJOL NO.38021-552 2794; 021-5523239|021-
5523239021-5525214 Y Y ALL COVERAGE
132 0833 RS. BUNDA SEJAHTERA JL. RAYA PURI AGUNG NO 3, KOTA BARU- PASAR KEMIS 021-5925876/5925889| 021-5925889 Y Y ALL COVERAGE
133 0844 RSIA. BUNDA SEJATI JL. PRABU SILIWANGI NO.11, JATIUWUNG 021-5900136 / 59315850| 021-5900056 Y Y ALL COVERAGE
Page 3 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
134 0859 RS. AMINAH TANGERANGJL. HOS COKROAMINOTO (CILEDUG RAYA) NO.4A KREO
SELATAN-LARANGAN
021-7371919/021-7371818|021-
7371818021-7371333 Y Y ALL COVERAGE
135 0872 RB & KLINIK MUTIARA OBBINI MEDIKA JL. RAYA KRESEK NO.27, DS.MERAK, BALARAJA 021- 59431110-|- 021-59430131 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
136 1014 RB & KLINIK PERMATA - DR JAMILAH JL. NUSA INDAH I, BLOK A7 NO.1, PERUM. CIBODAS 021-5533314| 021-5533314 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
137 1025 RS. ARIYA MEDIKA JL. INDUSTRI RAYA 1, BLOK A, NO.1-6, JATAKE 021-5902229/5902232-|- 021-5902223/5904951 Y Y ALL COVERAGE
138 0942 RSIA. MURNI ASIHJL. RAYA BOJONGNANGKA NO 86, MEDANG, PAGEDANGAN
TANGERANG
021-
36868757/5470263/54200982/54636
72021-5463755|021-5463755
021-54204504 Y Y ALL COVERAGE
139 1046 RSIA. PRATIWI JL. RHM NOERADJI, NO.42, KARAWACI021-5520692/71342783021-
43933978|021-43933978021-5224139 Y Y ALL COVERAGE
140 1049 KLINIK SELARASJL. RAYA SERPONG BSD SEKTOR IV,RUKO E.NO.43-45
SERPONG-TANGERANG021-5370311-|- 021-5377842 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
141 1168 RSU. BHAKTI ASIH JL. RADEN SALEH, NO.10, KARANG TENGAH 021-7305662/63/021-32575495| 021-73449491/7305652 Y Y ALL COVERAGE
142 0971 RS. ISLAM ASSHOBIRIN JL. RAYA SERPONG KM.11 PONDOK JAGUNG - SERPONG021-5384314; 021-5374293|021-
5374293021-5374392/5374294 Y Y ALL COVERAGE
143 2081 RS ARIA SENTRA MEDIKAJL. ARIA PUTRA NO. 9 KEDAUNG PAMULANG, TANGERANG
SELATAN021-7499199/ 7401376| 021-7495864/7400956 Y Y ALL COVERAGE
144 1555 RSIA. DHIAJL. CENDRAWASIH NO.90, SAWAH LAMA CIPUTAT,
TANGERANG SELATAN021-7494550/ 70310242| 021-7494551 Y Y ALL COVERAGE
145 1949 KLINIK & APOTEK KF 78 JL. A YANI NO 135 TANGERANG 021-5518433| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
146 1968 BETHSAIDA HOSPITALDISTRICT TIVOLLI NO. 1 PARAMOUNT SERPONG, JL.
BOULEVARD GADING SERPONG, TANGERANG021-29309999| 021-29305999 Y Y ALL COVERAGE
147 2360 RS. PERMATA IBU TANGERANG JL. KH. MAS MANSYUR NO.2 KUNCIRAN TANGERANG 021-7334343/ 7300883| - Y Y ALL COVERAGE
148 2440 LAB. PRODIA TANGERANGSUTERA NIAGA I NO. 21, RUKO ALAM SUTERA, SERPONG,
TANGGERANG 15325021-539 9961| 021-5312 2589 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
149 2347 RS. PERMATA PAMULANG JL. RAYA SILIWANGI NO. 1A, PAMULANG TANGERANG 021-74704999/74709079| - Y Y ALL COVERAGE
150 2609 KLINIK & APOTEK KF BERINGIN JL. BERINGIN RAYA NO.45, KARAWACI, TANGERANG 021 55763538| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
151 2469 KLINIK PRATAMAJL. CIRARAB RAYA NO.61 KEC. LEGOK TANGERANG -
BANTEN021- 54260359| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
152 1646 KLINIK JATI ELOK
KOMP. BUMI JATI ELOK BLOK A I NO 7, JL. RAYA LEGOK-
PARUNG PANJANG KM. 3,MALANGNENGAH, PAGEDANGAN,
TANGERANG, BANTEN
021-98496234| 021-5977529 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
153 2774 RSIA. INSAN PERMATAJL. BHAYANGKARA 1 NO.68 KEL. PAKUJAYA, KEC. SERONG
UTARA - TANGERANG SELATAN021-53121344| 021-5396733 Y Y ALL COVERAGE
154 2744 RSIA. AQIDAHJL. RADEN FATAH NO.40 PARUNG SERAB, CILEDUG,
TANGERANG021 73450244, 7319025| 7310851 EXT.222 Y Y ALL COVERAGE
155 2807 KLINIK PERTAMEDIKA PONDOK RANJIJL. WR SUPRATMAN NO. 43 (KAMP UTAN) TANGERANG
SELATAN021-7355253| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
156 3982 KLINIK & APOTEK KF PALEM SEMIJL. RUKO BARCELONA NO.23 PERUMAHAN PALEM SEMI
KARAWACI TANGGERANG02129662588| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
157 3983 KLINIK & APOTEK KF CITRARUKO TAMAN PALMA JL. RAYA BOULEVARD BLOK G1
NO.25R CITRA RAYA-CIKUPA02159409460| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
158 0021SILOAM HOSPITALS LIPPO VILLAGE
(KARAWACI)JL. SILOAM NO.6, LIPPO KARAWACI 1600 021-546 0055/25668000| 021-5460921/546008 Y Y ALL COVERAGE
159 1116RS. AWAL BROS TANGERANG (D/H RS.
GLOBAL MEDIKAJL. MH.THAMRIN NO.3 KEBON NANAS -CIKOKOL 021-55758888/55780888/55781234| 021-55781545 Y Y ALL COVERAGE
160 1223 EKA HOSPITAL BSD CENTRAL BUSINESS DISTRICT, LOT IX, BSD CITY 021-25655555| 021-25655544 Y Y ALL COVERAGE
161 1082 KLINIK TIGA MANDIRIJL. CABE RAYA NO 68D PONDOK CABE, TANGERANG
SELATAN021-7426366-|- 021-7426414 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
162 1552 BUNDA DALIMA HOSPITAL BUMI SERPONG DAMAI, SEKTOR XIV, BLOK J.11, NO.1 021-53154447/8/9| 021-5385062 Y Y ALL COVERAGE
163 1564 RSB. PERMATA SARANA HUSADA PAMULANG PERMAI, BLOK D3, NO.1-2, PAMULANG 021-7407421/22| 021-7496346/7407421 Y Y ALL COVERAGE
164 1527 RSIA. TIARA TANGERANG JL. RAYA SERANG, NO.1, KM.4.5, CIKUPA 021-59401999| 021-5960699 Y Y ALL COVERAGE
165 1528 RB & KLINIK ILANUR JL. RAYA SERANG, NO.1, BALARAJA 021-59450898/5953241| 021-5954473 Y Y ALL COVERAGE
166 1547 KLINIK AMIRAGRIYA LOKA SEK 1.6 BLOK A1 NO.3 BSD, TANGERANG
SELATAN021-5384219| 021-53164795 N Y
GP,SP,OP,DENTAL,MAT,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
167 1324 RSIA. CINTA KASIH JL. CIPUTAT BARU RAYA NO.10 CIPUTAT 021 - 74706020 / 7424639| 021 - 74707986 Y Y ALL COVERAGE
168 1366 KLINIK KARTIKAJL. WR SUPRATMAN NO.51 RENGAS CIPUTAT TIMUR,
TANGERANG SELATAN021-29053555,29053553| 021-73692937 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
169 1455 KLINIK PRADHANARUKO PANORAMA NIAGA NO.14-15 JURUMUDI BARU
BENDA021-55767587| 2159308529 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
170 1459 KLINIK KARUNIA SEHAT IIJL. PAHLAWAN SERIBU RAYA RUKO TOL BOULEVARD BLOK
B NO.18.BSD CITY021-53158045| 021-53158046 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
171 1471 KLINIK MELIA MEDIKAKOMP. RUKO DUTA GARDEN SQUARE BLOK C NO 2,
TANGERANG021-51488219/54370568| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
172 1575 MOM & CHILD CARE CLINICJL.RAYA KELAPA DUA RUKO PDA KAV.25-29 GADING
SERPONG021-54214848 / 083804104440| 021-54209393 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
173 1491 RS. HERMINA TANGERANG JL. KS.TUBUN NO.10 PASAR BARU 021-55772525| 021-5582705 Y Y ALL COVERAGE
174 1594 RSU. DINDA JL. GALUH NO.2 JATIUWUNG, TANGERANG 021-55650577| 021-55652149 Y Y ALL COVERAGE
175 1598RS. KARANG TENGAH MEDIKA (GROUP
YADIKA)JL. KARYAWAN IV, KARANG TENGAH TANGERANG 021-7336699/7335599| 021-7333598 Y Y ALL COVERAGE
176 1340 RSIA. KELUARGA KITA JL. RAYA PLP CURUG KM. 4 NO. 8, DS SUKABAKTI CURUG 021 - 59491011 / 021 - 5986572| 021-5984991/5982788 Y Y ALL COVERAGE
177 1292 RS. MEDIKA BSDJL. LETNAN SOETOPO KAV. KOM. III A NO 7, BSD
TANGERANG021 - 5372296| 021 - 5382296 Y Y ALL COVERAGE
178 0017 RS. AN-NISA TANGERANG JL. GATOT SOEBROTO, NO.96, KM.3, CIBODAS021-5525564/021-557 91563|021-
557 91563021-55791563 Y Y ALL COVERAGE
179 1086 RSU. SARI ASIH SANGIANG JL. RAYA MAUK.KM.3,5 SIMPANG TIGA SANGIANG 021-5582732-|- 021-55791307 Y Y ALL COVERAGE
180 1768 KLINIK SATELIT GSM TANGERANGJL. KH. HASYIM ASHARI BABAKAN TANGERANG, RUKO
MODERNLAND BLOK AR NO 19-20021-55748000| 021-4254816 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 4 of 40
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
181 1985 RS. MEDIKA LESTARIJL. HOS COKROAMINOTO PERUM PONDOK LESTARI BLOK
C.1 NO.1-2 CILEDUG021-5854858| 021-7304150/021-7320 Y Y ALL COVERAGE
182 4321 JAKARTA BOUTIQUE DENTAL CENTER (JBDC)JL. MALEO RAYA BLOK . JE 8/9 BINTARO, PONDOK
PUCUNG, PONDOK AREN, TANGERANG SELATAN021 745 8195| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
183 0772 MEDIPRO CLINIC PASAR KEMISPERUM WISMA MAS, BLOK A1, NO.30-31, PASAR KEMIS,
KUTA JAYA021-59318964| 021-59318965 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
184 0955DENTAL PREMIER BINTARO ( D/H DENTAL
INTERNASIONALJL. MH THAMRIN NO.1, SEKTOR 7, BINTARO JAYA
021-745 5500; 021-27625500 ext
1680|-021-748 64854/745 58 N Y DENTAL
185 0737 RS. USADA INSANI JL. KH HASYIM ASHARI NO.24 CIPONDOH, TANGERANG
021-55752575/5521270021-
55755665/5521272|021-
55755665/5521272
021-55754335 Y Y ALL COVERAGE
186 1619 RSIA. BUAH HATI PAMULANG JL. RAYA SILIWANGI NO 189 PONDOK BENDA PAMULANG 021-7414488| 021-7420322 Y Y ALL COVERAGE
187 0733 RS. OMNI ALAM SUTERA JL. ALAM SUTERA BOULEVARD KAV.25 SERPONG021-29779999/85550711 -
353438|0711 - 353438021-5312 8666 Y Y ALL COVERAGE
188 2819 LAB. PRODIA BUMI SERPONG DAMAI (BSD)JL. LETNAN SUTOPO, RUKO GOLDEN MADRID BLOK B NO.1-
2, BUMI SERPONG DAMAI021-53160403/4| 021-53160406 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
189 3791 RSB. CITRA ANANDA JL. RE MARTADINATA NO. 30, CIPUTAT (021) 7401347| (021) 7491701 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
190 3047 RSIA. VITALAYAPERUMAHAN PONDOK BENDA INDAH JL. SILIWANGI NO 1
PAMULANG021-7470 3313| - Y Y ALL COVERAGE
191 3978 KLINIK & APOTEK KF 447 CIRENDEU JL. CIRENDEU RAYA NO.27C CIPUTAT 021-7415997| -021-7415997 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
192 3999 KLINIK PESONA LEGOKJL. RAYA LEGOK KM 7 DESA CIJANTRA KEC. LEGOK,
KARAWACI, TANGERANG, BANTEN021-54220281| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
193 2337 KLINIK TUMBURJL.PAHLAWAN NO.4 SITUGINTUNG REMPOA CIPUTAT
TIMUR0217492818| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
194 0936 RS. SARI ASIH CILEDUG JL. HOS COKROAMINOTO NO.38 CILEDUG021-7333430/ 33553359021-
7332758|021-7332758021-7333441 Y Y ALL COVERAGE
195 1467 RSIA. MUTIARA BUNDA TANGERANG JL. DR. CIPTO MANGUNKUSUMO, NO.3, CILEDUG 021-7301365/73454951| 021-73454952 Y Y ALL COVERAGE
196 1608 RS. SARI ASIH CIPUTATJL. OTISTA RAYA NO. 3 SASAK TINGGI CIPUTAT,
TANGERANG SELATAN021-7410808| 021-7424445 Y Y ALL COVERAGE
197 1020 RSIA. SELARAS CIKUPA JL. RAYA SERANG KM.18,5 DS BOJONG, CIKUPA021-5969145/59401289/021-
59401277|021-59401277 Y Y ALL COVERAGE
198 2504 RS. HERMINA SERPONGJL. RAYA PUSPITEK KM.8 NO.99, SERPONG, TANGERANG
SELATAN(021) 7588 4999| 021 - 75883704 Y Y ALL COVERAGE
199 4695 RS. TIARA TANGERANGJL. BRINGIN RAYA NO. 3-4-5, KEL. NUSAJAYA, KEC.
KARAWACI, TANGERANG(021) 29238000| (021) 29237999 Y Y ALL COVERAGE
200 3532 CLINIC ICON 8JL. HORISON BROADWAY BLOK M2 NO. 3 BSD CITY ,
TANGERANG(021) 33438000/ 021 94588000| (021) 68538820 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
201 4747 RS. HERMINA BITUNGJL. RAYA SERANG KM. 10 RT 001/RW 004 KEL. CURUNG
DESA KADU. KAB. TANGERANG021-59497525| 021-59497690 Y Y ALL COVERAGE
202 4657 RSIA. BUN
JL. RAYA KOSAMBI TIMUR RAYA NO. 2, RT. 011/ RW. 004,
KEL. KOSAMBI TIMUR, KEC. KOSAMBI, TANGERANG,
BANTEN
(021) 70610735; 29031299| - Y Y ALL COVERAGE
203 4684 KLINIK ALFAKOMP. RUKO W.S FAMILY, JL. GARUDA NO.10/3, KEL.
BATU CEPER, TANGERANG(021) 95000408| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
204 3979 KLINIK & APOTEK KF 267 BINTARO JL. BINTARO UTAMA V BLOK EA 2 NO.35 BINTARO 021-7371018| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
205 4697 KLINIK ICHSAN BINTARO
KEBAYORAN ARCADE III BLOK KA/E 1-22, JL. BOULEVARD
BINTARO JAYA SEKTOR 7/ BINTARO JAYA - TANGERANG
SELATAN 15229
-| (021) 2952 1655 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
206 2863 LAB. PRODIA BINTAROJL. RUKO KEBAYORAN ARCADE 2 SEKTOR 7, BLOK 33-35,
BINTARO-TANGERANG021-7370185; 29511799| 021-29511798 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
207 3701 PRODIA GADING SERPONGRUKO PARAMOUNT CENTER 1A/ 32 JL. KELAPA DUA,
GADING SERPONG, TANGERANG(021) 29014884, 29014885| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
208 1774 RS. DR. SUYOTO PUSREHAB KEMHAN JL. RC VETERAN NO. 178 BINTARO 021-7342012 / 73884000| 021-7342581, 7369156 Y Y ALL COVERAGE
209 1682 RSU. ST CAROLUS SUMMARECON JL. GADING GOLF BOULEVARD KAV. 08 GADING SERPONG 021-54220811| 021-54220810 Y Y ALL COVERAGE
210 1947 KLINIK & APOTEK KF 219 JL. IR H JUANDA NO 111 SITUGINTUNG, CIPUTAT 021-7401868| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
211 1810 RS. KHUSUS BEDAH THT PROKLAMASI BSDCOMMERCIAL PARK CENTRAL BUSINESS OF DISTRICT BSD
KAV.7 TANGERANG SELATAN021-29002929| 021-29002930 Y Y ALL COVERAGE
212 1935 APOTIK FARMARIN IV BINTARO BINTARO UTAMA SEKTOR 3 BLOK AM, BINTARO JAYA 021-7357077| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
213 1948 KLINIK & APOTEK KF 115 JL. PAMULANG PERMAI RAYA NO D2/1A TANGERANG 021-7498708| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TANGERANG SELATAN
214 5550 FRIENDLY DENTAL CARE BSD RUKO BIDEX B16, BSD CITY, SERPONG 021-531164571, 08158939191|N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BENGKULU
BENGKULU
215 2109 APOTEK KIMIA FARMA 220 BENGKULU JL. S. PARMAN BENGKULU -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
216 5415 KLINIK RAWAT INAP RAFAELA KENCANAJL. FLAMBOYAN DESA GIRI KENCANA NO. 104 KETAHUN
BENGKULU UTARA, BENTONG(085268347777)| - N Y ALL COVERAGE
217 0848 RS. TIARA SELLA JL. S PARMAN NO. 61 PADANG JATI, BENGKULU0736-20350 021-8221574|021-
82215740736-20626 Y Y ALL COVERAGE
218 2108 APOTEK KIMIA FARMA 72 BENGKULU JL. SUPRAPTO NO. 48 BENGKULU 0736-20601| 0736-20601 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
219 1551 RS. BHAYANGKARA BENGKULU JL. VETERAN, NO.2 0736-341086/21553| 0736-349050 Y Y ALL COVERAGE
220 1021 RS. RAFFLESIA BENGKULU JL. MAHONI, NO.10, PADANG JATI 0736-21710-|- 0736-342677/21954 Y Y ALL COVERAGE
DAERAH ISTIMEWA YOGJAKARTA
BANTUL
221 1437 RS. PKU MUHAMMADIYAH BANTUL JL. JEND. SUDIRMAN 124-126 0274-368587| 0274-368586 Y Y ALL COVERAGE
SLEMAN
222 4170 KLINIK PRATAMA DKJL. RING ROAD UTARA NO. 17 A KARANGNANGKA RT 07
RW 13, MAGUWOHARJO DEPOK SLEMAN0274-4333679| 0274-4333679 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
223 1674 RS. PKU MUHAMMADIYAH UNIT II JL. WATES KM 5,5 GAMPING SLEMAN YOGYAKARTA 0274-6499704/6499706| 0274-6499727 Y Y ALL COVERAGE
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
224 2974 RSI. YOGYAKARTA PDHI JL. SOLO KM. 12,5 KALASAN, SLEMAN, YOGYAKARTA (0274) 498000| (0274) 498464 Y Y ALL COVERAGE
225 1229 JOGJA INTERNATIONAL HOSPITAL (JIH) JL. RING ROAD UTARA NO.160 CONDONG CATUR SLEMAN 0274-4463535/4463190| - LIHAT REMAKS Y Y ALL COVERAGE
226 3088 RSU. QUEEN LATIFAJL. RING ROAD BARAT NO. 118 MLANGI NOGOTIRTO
GAMPING SLEMAN0274-581402| 0274-626309 Y Y ALL COVERAGE
227 4334 RS. HERMINA YOGYAJL. MATARAMAN HERMINA RT 06 RW 50 GONDANGAN
RINGINSARI MAGUWOHARJO, DEPOK0274-2800808/2800909| 0274-2800909 Y Y ALL COVERAGE
YOGYAKARTA
228 3297 LAB. CITO YOGYAKARTA JL. ATMOSUKARTO NO. 4 KOTABARU YOGYAKARTA 0274 563656| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
229 0606 RS. PKU MUHAMMADIYAH YOGYAKARTA JL. K.H. ACHMAD DAHLAN, NO.20 0274-512653-|- 0274-566129 Y Y ALL COVERAGE
230 0747 RS. PANTI RAPIH JL. CIK DITIRO, NO.30 0274-514014/514845/563333| 0274-564583 Y Y ALL COVERAGE
231 2616 KIMIA FARMA 401 JL. SETURAN,C 3/B, JOGJA 0274 4332880| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
232 2617 KLINIK & APOTEK KF 275 JL. KALIURANG, JOGJA 0274 885220| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
233 2618 KLINIK & APOTEK KF 70 JL. ADISUCIPTO 63A, JOGJAKARTA 0274 489135| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
234 2619 KLINIK & APOTEK KF 316 JL. PALAGAN, JOGJA 0274 869944| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
235 2864 RS. AN NUR JL. N.COLOMBO, NO. 14, YOGYAKARTA 0274-585848/0274-514784| 0271-564110 Y Y ALL COVERAGE
236 2768 KIMIA FARMA 21 JL. MALIOBORO - YOGYA 0274 514980| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
237 2170 APOTEK FARMARIN YOGYAKARTA JL. P. MANGKUBUMI NO.73 YOGYAKARTA 0274-7822198| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
238 0077 RS. BETHESDA YOGYAKARTA JL. JEND.SUDIRMAN NO.700274-586688/5622460274 -
586688|0274 -5866880274-563312,521251 Y Y ALL COVERAGE
239 1400 RSU. BETHESDA LEMPUYANGWANGI JL. HAYAM WURUK NO.6 0274-512257/588002| 0274-547253 Y Y ALL COVERAGE
240 0604 RS. LUDIRA HUSADA TAMA JL. WIRATAMA NO.4 TEGALREJO 552440274 2871840/ 620333/620373/0274-
620091|0274-6200910274-589087 Y Y ALL COVERAGE
241 2909 LAB. PRODIA BINTARAN YOGYAKARTA JL. BINTARAN KULON NO. 28 YOGYAKARTA 55151 0274-373271/375273| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
242 2908 LAB. PRODIA MANGKUBUMI YOGYAKARTA JL. PANGERAN MANGKUBUMI NO. 50 YOGYAKARTA 55232 0274-580675/515818| 0274-584911 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
243 4036 KLINIK KHADIJAH JL. PURWANGGAN NO. 45 0274-513357| 0274-513357 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
244 1255 RS. MATA DR.YAP JL. TEUKU CIK DITIRO, NO.5 0274-562054| - Y Y ALL COVERAGE
DKI JAKARTA
JAKARTA BARAT
245 0204 RS. MEDIKA PERMATA HIJAU JL. RAYA KEBAYORAN LAMA, NO.64021 - 530 5288, 534 7411,021 - 534
741|021 - 534 741021-53652856/5305291 Y Y ALL COVERAGE
246 0695 KLINIK KUSUMA I JL. PETA SELATAN, NO.50 kalideres 021-541 9747| 021-54360626 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
247 5539 KLINIK TERATAI KEBON JERUKJL. KEBON JERUK RAYA NO. 68 RT. 001 RW. 011 KEL.
KEBON JERUK KEC. KEBON JERUK, JAKARTA BARAT(021) 22534039| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
248 0952 RS. PATRIA IKKT JL. CENDRAWASIH NO.1 KOMP DEPHAN/MABES TNI 021-5308981-84-|- 021-5346387 Y Y ALL COVERAGE
249 4492 KLINIK VIVA MEDIKA CENTRO CITYJL. MACAN KAV. 4-5 BLOK S 16 &RT 010/001, KEL.
KEDOYA UTARA KEC. KEBON JERUK, JAKARTA BARAT(021) 29666764 / 50200730| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
250 4678 KLINIK BAMEDJL. PENYELESAIAN TOMANG IV KAVLING. DKI BLOK 95 NO.
1, MERUYA UTARA - KEMBANGAN021 - 584 3456 / 584 46512| (021) 5867004 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
251 5078 RSIA. BINA SEHAT MANDIRIJL. DURI RAYA NO. 22 KEL. DURI KEPA KEC. KEBON
JERUK, JAKARTA BARAT(021) 5669411/12| (021) 5658870 Y Y ALL COVERAGE
252 4686 RS. CIPUTRA CITRA GARDEN CITY
JL. BOULEVARD BLOK G-01/01 5 CITRA GERDEN CITY,
KRL. PEGADUNGAN KEC. KALIDERES JAKARTA BARAT
11830
(021) 2255 7888| - Y Y ALL COVERAGE
253 4770 KLINIK CIPUTRA CITRA GARDEN CITYJL. CITRA 2 BLOK J 2 CITRA GARDEN CITY RT. 002/RW.
012 KEL. PEGADUNGAN KEC. KALIDERES, JAKARTA BARAT021-29038871-3| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
254 0101 SILOAM HOSPITALS KEBON JERUK JL. RAYA PERJUANGAN, KAV.8, KEBON JERUK021- 25677888/021-5300889|021-
5300889021-5321766 Y Y ALL COVERAGE
255 4353 MITRA KELUARGA KALIDERES JL. PETA SELATAN NO. 1 RT 007/011 KALIDERES 021-22523700| 021-22523702 Y Y ALL COVERAGE
256 3211 GETHEALTHY CLINICRUKAN SIXTH AVENUE J01 A NO. 20-22, CITRA 6,
KALIDERES, JAKARTA BARAT021-29030041/42| 021-29030045 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
257 3735 PRODIA KEDOYA-JL. KEDOYA AGAVE RAYA, PERKANTORAN TOMANG TOL
RAYA BLOK A II/22, JAKARTA BARAT 11520(021) 5803066, 5812941| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
258 4679 KLINIK KLJL. ARIES UTAMA BLOK E.1 NO. 1 N-M, KEL. MERUYA
UTARA, KEC. KEMBANGAN, JAKARTA BARAT(021) 29415300| 021-29319150 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
259 3601 PRODIA CIDENG JL. CIDENG BARAT NO. 36 A, JAKARTA PUSAT 10150 (021) 6321820| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
260 4514 PRODIA DAAN MOGOT BARU JL. TAMPAK SIRING BLOK KJG NO. 10 JAKARTA 021-54392150-29038204| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
261 4822 KLINIK MAYAPADA CENTRAL PARK
JL. TANJUNG DUREN RAYA GRAND SHOPPING ARCADE
BEAUFORT 8 NO. AC, KEL. TANJUNG DUREN SELATAN,
KEC. GROGOL PETAMBURAN, JAKARTA BARAT
(021) 29859901| - Y YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
262 2640 KLINIK & APOTEK KF 254 JL. RAYA POS PENGUMBEN NO.11 JAKARTA BARAT 021 5349063| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
263 3977 KLINIK & APOTEK KF 282 JL. AIPDA KS TUBUN NO.84 B-C JAKARTA 081372756593| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
264 3166 LAB. PRODIA PURI INDAHKOMPLEK SENTRA NIAGA PURI INDAH BLOK T/6 NO.28, JL.
PURI LINGKAR DALAM JAKARTA BARAT021-58304501| N Y GP,LAB
Page 6 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
265 1945 KLINIK & APOTEK KF 96 JL. LET JEND S PARMAN KAV G/12, SLIPI, JAKARTA BARAT 021-5303347/57| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
266 2294 RS. JAKARTA EYE CENTER KEDOYAJL. TERUSAN ARJUNA UTARA NO. 1 KEDOYA, JAKARTA
BARAT 11520021-29221000| - Y Y ALL COVERAGE
267 1102 RS. BHAKTI MULIA JL. AIPDA K.S.TUBUN, NO.79 021-5481625-|- 021-5331544 Y Y ALL COVERAGE
268 1127 JESSLYN MEDICAL CENTER PERUM.TAMAN SURYA III BLOK F/63 CENGKARENG 021-54365638| 021-54365638 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
269 1479 RS. PONDOK INDAH PURI INDAH JL. PURI INDAH RAYA BLOK S2, KEMBANGAN SELATAN 021-25695222/25695200| 021-25695265 Y Y ALL COVERAGE
270 0736 RSUD. CENGKARENGJL. N. KAMAL RAYA, BUMI CENGKARENG INDAH,
CENGKARENG TIMUR021-54372874/5/6 / 54372882| 021-54374579 Y Y ALL COVERAGE
271 0390 RS. HERMINA DAAN MOGOT JL. KINTAMANI RAYA, NO.2, KAW. DAAN MOGOT BARU 021-5408989| 021-5449869 Y Y ALL COVERAGE
272 0643 RS. GRHA KEDOYA JL. PANJANG NO 26, KEDOYA UTARA 021-56982222/29910999| 02129910987/56982233 Y Y ALL COVERAGE
273 0381 KLINIK MHT CENGKARENG JL. DAAN MOGOT, KM.17 021-54396298/6194581| 021-6194581 N Y ALL COVERAGE
274 0109 RSAB. HARAPAN KITA JL. JEND S.PARMAN, KAV.87, SLIPI021-5668284/5686404/5683053021-
566 8284|021-566 8284021-5601816,5668285 Y Y ALL COVERAGE
275 0836 RS. ROYAL TARUMA JL. DAAN MOGOT NO.34 GROGOL 021-56958338/56967788-|- 021-56958589 Y Y ALL COVERAGE
276 0783 KLINIK MHT KALIDERESJL. PETA SELATAN RAYA-KALIDERES INDAH I BLOK A
NO.2021- 5456027| 021- 5456027 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
277 0782 KLINIK MHT ANGKEJL. TUBAGUS ANGKE NO.27. TAMAN DUTA MAS BLOK D-
9B NO.2-3021- 5675259/5679165| 021-5679165 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
278 0771 KLINIK YADIKA TEGAL ALUR JL. KAMAL RAYA BLOK A7 NO.7-11 TEGAL ALUR 021-70605247 / 55351876| 021-55963484 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
279 0846 RS. JANTUNG HARAPAN KITA JL. LETJEN S PARMAN KAV.87 SLIPI 021-5684093 / 5684085| 021-5601816 Y Y ALL COVERAGE
280 0943 KLINIK MATA NUSANTARA (KEBON JERUK) JL.ARJUNA UTARA NO.50, KEBON JERUK 11510 (021) 564 6688|- (021) 564 2072 N Y GP,OP
281 0018 RS. PELNI JL. AIP II K.S. TUBUN, NO.92-94, PETAMBURAN
021-5306901-
9/5349475/5460608/5484809021-
5484809|021-5484809
0215483145/5306904/7 Y Y ALL COVERAGE
JAKARTA PUSAT
282 0788 RSPAD GATOT SUBROTO (PAV.KARTIKA) JL. ABDUL RACHMAN SALEH NO.24021-384 0484, 3441008021-
376134|021-376134021-3859460,3501308 Y Y ALL COVERAGE
283 0599 RS. KRAMAT 128 JL. KRAMAT RAYA, NO.128 021-3909814/3918287/3909514| 021-3909125 Y Y ALL COVERAGE
284 0029 RSU. EVASARI JL. RAWAMANGUN NO.47 - PRAMUKA 021-4202851/52| 021-4209725 Y Y ALL COVERAGE
285 0787 RS. KHUSUS THT-BEDAH PROKLAMASI JL. PROKLAMASI NO.43
021-
3900002/3906893/3144795/3909783
|
021- 3900947/3152548 Y Y ALL COVERAGE
286 0790 RSIA. BUNDA JAKARTA JL. TEUKU CIK DITIRO NO.28, MENTENG(021) 3143215(021) 31922005|(021)
31922005021-3101313,3928588 Y Y ALL COVERAGE
287 1115 RSPAD GATOT SUBROTO (PAV.IKA) JL. ABDUL RACHMAN SALEH NO.24 021-3504614| 021-3520643 Y N ALL COVERAGE
288 2793 KLINIK PERTAMEDIKA KWARNAS JL. MEDAN MERDEKA TIMUR NO. 6 JAKARTA PUSAT 021-3502150 EXT 1998| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
289 3972 KLINIK MIRACLE GRAND INDONESIA MENARA BCA LT.9 JL. MH. THAMRIN, JAKARTA PUSAT (021) 23587188 EXT.10511| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
290 1026 RSIA. TAMBAK JL. TAMBAK,NO.18 MANGGARAI 021-2303444/087880676072|- 021-3902550 Y Y ALL COVERAGE
291 1197 RSPAD GATOT SUBROTO (NON. PAV) JL. ABDUL RACHMAN SALEH NO.24 021-3448929| 021-3448929 Y N ALL COVERAGE
292 2637 KLINIK & APOTEK KF 2 JL. RAYA SENEN NO. 66 021 384-4788; 384-0742| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
293 4238 MP DENTAL CENTER
HOTEL INTERCONTINENTAL LG FLOOR R27-28, JL. JEND
SUDIRMAN KAV.10-11, KEL. KARET TENGSIN, KEC. TANAH
ABANG
(021) 5735336| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
294 2507 MITRASANA IHC KALBE CEMPAKA PUTIHJL. LETJEN SUPRAPTO KAV 4 CEMPAKA PUTIH, JAKARTA
PUSAT021-42873888 EXT : 1451| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
295 4228 RS. LADOKGI JL. FARMASI NO.1, TANAH ABANG, JAKARTA PUSAT (021) 573 3026| -Y Y
ALL COVERAGE
296 4375 KLINIK MATA NUSANTARA (Kemayoran)GEDUNG DATA SCRIPT LT.6 KAWASAN NIAGA SELATAN
BLOK B-15, KEMAYORAN(021) 654 6688| (021) 654 5208 N Y GP,OP
297 4662 KLINIK & APOTEK KF PPBM BANK MANDIRI JL. RP.SOEROSO NO.9 CIKINI -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
298 1495 APOTEK & KLINIK KF INDOSATGD. INDOSAT LT.23 JL. MEDAN MERDEKA BARAT NO. 1
JAKARTA PUSAT021-30003750| 021-30003750 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
299 1054 RS. HUSADAJL. RAYA MANGGA BESAR 137-139, JAKARTA PUSAT BAG
UTARA
021-6260108/021-6490090|021-
6490090021-6497494 Y Y ALL COVERAGE
300 4804 KLINIK ASHA JL. JOHAR NO. 1A MENTENG, JAKARTA PUSAT (021) 3905035 / 3905037/ 2305326| (021) 3928907 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
301 4058 KLINIK GRAHA PT YPK MANDIRIGEDUNG GRAHA MANDIRI LT.1 LOBBY SELATAN,JL. IMAM
BONJOL NO.61021 - 39838556| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
302 2636 KLINIK & APOTEK KF 1 JL. GARUDA NO.47, JAKPUS 021 424-5572| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
303 2794 KLINIK PERTAMEDIKA KANTOR PUSAT JL. PERWIRA 2 - 4 JAKARTA PUSAT 021-3816104/3815970/3815687| -- N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
304 2733 KINAN MEDICAL CENTERKOMPLEK RUKO RAWASARI MAS NO.B10 JL. PERCETAKAN
NEGARA, CEMPAKA PUTIH JAKARTA PUSAT-| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
305 2735 THOMSON SPECIALIST CENTER JL. IMAM BONJOL NO.72, MENTENG JAKARTA PUSAT 10310 021-3910030| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
306 1633 KLINIK GARUDA SENTRA MEDIKA ( GSM ) JL. ANGKASA BLOK B.15 KAVLING 1, KEMAYORAN 021-4241000| 021-4254816 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
307 1232 LAB. KLINIK PRODIA KRAMAT JL. KRAMAT RAYA NO.150 021 - 3906709| 021- 3922721 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
308 2405 HENDRA HIDAYAT IMPLANT CENTERSAHID SUDIRMAN RESIDENCE LT. 1 UNIT 1, JL. JEND.
SUDIRMAN NO. 86 JAKARTA PUSAT021-52970102/104| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
309 1954 RS. UPN CIPTO MANGUNKUSUMO (KENCANA) JL. DIPONEGORO NO. 71 JAKARTA PUSAT 1500135 , 021 - 92005164| - Y Y ALL COVERAGE
310 1709 KLINIK WISMA PT YPK MANDIRI WISMA MANDIRI LT I, JL. MH THAMRIN NO 5 021-39832805| 021-39832806 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
311 1700 FHL DENTAL CLINICGEDUNG BRI II LT.15 SUITE 1509 JL. JEND SUDIRMAN NO
44-46021-57851127/ 57930552| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
312 1702 RS. KHUSUS BEDAH SS MEDIKA JL. SALEMBA I NO 11 JAKARTA PUSAT 021-3913336/3926689| 021-3926687 Y Y ALL COVERAGE
Page 7 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
313 1820 RSU. BUNDA JAKARTA JL. TEUKU CIK DITIRO NO.21, MENTENG 021-31923344/ 31922005| - Y Y ALL COVERAGE
314 1914 RSUD. TARAKAN JL. KIYAI CARINGIN NO 7, JAKARTA PUSAT 021- 3503003, 3842934, 3503150| 021-3810149, 3503412 Y Y ALL COVERAGE
315 0600 RS. ST. CAROLUS JL. SALEMBA RAYA, NO.41 021-3904441| 021-3922831/3154183 Y Y ALL COVERAGE
316 2406 HENDRA HIDAYAT DENTAL CENTER (HHDC)THAMRIN CITY - OFFICE SUITE FLOOR 3 UNIT 2, JL. KH.
MAS MASYUR JAKARTA021-3199 7482| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
317 1387 BRAWIJAYA CLINIC UOBJL. MH THAMRIN NO 10, ANZ SQUARE (UOB PLAZA)
BASEMENT 1 UNIT C 1-3021-29261880| 021-29261890 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
318 1406 APOTIK FARMARIN I KEBON SIRIHGEDUNG BANK INDONESIA JL. KEBON SIRIH NO 82 DAN
84 GEDUNG KEBON SIRIH LT 1021-29810000 / 29815268| 021-2311940 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
319 1069 RSPAD GATOT SUBROTO(P.IMAM SUJUDI) JL. ABDUL RAHMAN SALEH NO.24 021-3441008-|- 021-3859460 Y N ALL COVERAGE
320 1078 RSIA. BUDI KEMULIAAN JL. BUDI KEMULIAAN NO.25 021-3842828-|- 021-3501012 Y Y ALL COVERAGE
321 1358 RSIA. YPK MANDIRI JL. GEREJA THERESIA, NO. 22 021-3909725| 021-3909806 Y Y ALL COVERAGE
322 1477 BUNDA INTERNASIONAL CLINIC JL. TEUKU CIK DITIRO NO.12, MENTENG 021-3926393| 021-3926494 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
323 0013 RS. PGI. CIKINI JL. RADEN SALEH, NO.40 021-38997777| 021-324663/ 3910277 Y Y ALL COVERAGE
324 1590 RS. BEDAH THT PROF. NIZAR JL. KESEHATAN NO.9 021- 3503435/34834982| 021-34834982 Y Y ALL COVERAGE
325 1612 LAB. KLINIK BIOTEST MENTENG JL. SUMATERA RT. 002 / 04, MENTENG 021-31937784| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
326 1577 KLINIK MIRACLE ( GD INDOFOOD )INDOFOOD TOWER - PLAZA SUDIRMAN LT 8, JL. JEND
SUDIRMAN KAV 76-78021-57954537/38| 021-57954541 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
327 0953 RS. ISLAM JAKARTA (CEMPAKA PUTIH) JL. CEMPAKA PUTIH TENGAH I/1021-4250451/42801567021-
42801567|021-42801567021-4266546 Y Y ALL COVERAGE
328 1105 RS. JAKARTA EYE CENTER MENTENG JL. CIK DITIRO 46,MENTENG JAKARTA 10310021-29221000021-31935600|021-
31935600021-3904601 Y Y ALL COVERAGE
329 0084 RS. JAKARTA JL. JEND. SUDIRMAN, KAV.49021-5732241/5741828021-
5741828|021-5741828021-5719870 Y Y ALL COVERAGE
330 0042 RS. PERTAMINA JAYA JL. A. YANI NO.2021-4204056/4211911021-
4211911|021-4211911021-4211913 Y Y ALL COVERAGE
331 0135 RS. ABDI WALUYO JL. H.O.S. COKROAMINOTO, NO.31-33 021-3144989| 021-31930866 Y Y ALL COVERAGE
332 0793 KLINIK YES CARE JL. WAHID HASYIM NO. 31C 021-3915487| 021-3146659 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
333 0789 KLINIK MHT SERDANG JL. H. UNG E - 71/2 KEMAYORAN 021-4249519| 021- 4249519 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
334 0802 SAHID SAHIRMAN MEMORIAL HOSPITAL JL. JEND.SUDIRMAN, NO.86021- 57853911 / 5727210|021-
5727210021- 57853922 Y Y
H&S,GP,SP,OP,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
335 0398 RS. MH. THAMRIN INTERNASIONAL JL. SALEMBA TENGAH, NO.26-28 021-3904422| 021-3926934,3926931 Y Y ALL COVERAGE
336 0705 KLINIK SWA INDOMEDIKA JL. JEND SUDIRMAN KAV 1, GD BNI LANTAI BASEMENT 1 021-5728987| 021-5728990 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
337 0397 KLINIK BARUNA JL. CIKINI RAYA, NO.60 R/S 021-3141040-059| 021-3151065 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
338 0011 RS. MITRA KELUARGA KEMAYORAN JL. LANDAS PACU TIMUR, KEMAYORAN 021-6545555/888| 021-6545959 Y Y ALL COVERAGE
339 1019 RSPAD GATOT SUBROTO (P.DARMAWAN) JL. ABDUL RACHMAN SALEH NO.24021-3840484/3500004/021-
376134|021-376134021-3441903/3859460 Y Y ALL COVERAGE
340 0392RS. HERMINA KEMAYORAN (d/h RSIA
HERMINA PODOMORO)
JL. SELANGIT BLOK B.10, KAV. 4 KEL GUNUNG SAHARI,
KEMAYORAN, JAKARTA PUSAT021-22602525 WA 085694155353| - Y Y ALL COVERAGE
JAKARTA SELATAN
341 1089 RS. KHUSUS THT & BEDAH CIRANJANG JL. CIRANJANG NO.20-22 KEB.BARU021-7243366/7208192/7208192|021-
7208192021-7264038 Y Y ALL COVERAGE
342 1554 H2E DENTAL CLINICMENARA KUNINGAN,JL. HR. RASUNA SAID BLOCK X-7
LT1. UNIT I, KUNINGAN021-30040151/152| 021-30040152 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
343 1458 MULIA HEALTH AND DENTAL CARE (MHDC)GEDUNG MENARA MULIA, SUITE LG, JL. JEND.GATOT
SUBROTO, KAV.9-11021-5223838| 021-52901073 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
344 0799 RS. GANDARIA JL. GANDARIA TENGAH II, NO.12-14, KEBAYORAN BARU 021- 7250718/ 7203311| 021- 7222038 Y Y ALL COVERAGE
345 0800 KLINIK TRIAZ PERSADA GRAHA NIAGA TOWER LT.B1, JL. JEND. SUDIRMAN NO.58 021- 2505250| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
346 0193 RSIA. BUDHI JAYA JL. DR. SAHARJO, NO.120021-8292672/8311722021-
8311722|021-8311722021-8301901 Y Y ALL COVERAGE
347 0890 KLINIK INTERMED HEALTH & BEAUTY JL. KEBAGUSAN 1 NO. 8 JAKARTA SELATAN 12520 021-7823501| 021-7823502 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
348 0112 SUDIRMAN MEDICAL CENTER JL. KARET BELAKANG TIMUR NO. 17 021-5203467/96277627| 021-5203468 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
349 0034 ADITYA MEDICAL CENTER JL. ADITYAWARMAN I, NO.14, KEBAYORAN BARU 021-7228639| 021-7228922 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
350 0041 RS. AGUNG JL. SULTAN AGUNG, NO.67, PASAR RUMPUT0218294955,8305768/9,8282795,83
794207|021-8305791 Y Y ALL COVERAGE
351 0043 RS. JAKARTA MEDICAL CENTER JL. BUNCIT RAYA, NO.15 021-7980888/7985177| 021-7940838 Y Y ALL COVERAGE
352 0199 MEDICARE CLINICMENARA KADIN INDONESIA, 27TH FLOOR, JL. H.R.
RASUNA SAID, BLOK X-5, KAV.2-3021-57903905| 021-5274754 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
353 0775 RSIA. DUREN TIGA JL. DUREN TIGA RAYA, NO.5, PANCORAN 021- 794 1843 / 7993817 /7948696| 021- 790 1050 Y Y ALL COVERAGE
354 0401 KLINIK SPESIALIS & APOTIK, RSB. ESTI JL. BANGKA RAYA, NO.28-30, PELA MAMPANG 021-7194434-35| 021-71791917 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
355 0892 KLINIK FAMILY DENTISTRY JL. PANGLIMA POLIM II/2 021-7267267-021 7221266|- 021 7264365 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
356 0911 KLINIK MEDIKA PLAZA KARTIKA CANDRAKARTIKA CHANDRA HOTEL, JL. JEND GATOT SOEBROTO
KAV 18-20
021-5251207021-5205000|021-
5205000021-5265921
N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
357 0400 MEDIKALOKA HEALTHCARE CENTER
RDTX TOWER GROUND & 2 ND FLOOR. JL.
PROF.DR.SATRIO KAV. E IV NO.6 MEGA KUNINGAN,
JAKARTA SELATAN
021-5261118| 021-5261119 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
358 0003 RS. TEBET JL. MT. HARYONO, NO.8, PANCORAN 021-8307540 / 829154| 021-8311760 Y Y ALL COVERAGE
359 2931 APOTEK KIMIA FARMA DUREN TIGA PLN PUSLITBANG JL. DUREN TIGA NO 102 JAKARTA 12760 -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
360 0049 RS. PONDOK INDAH JL. METRO DUTA, KAV. UE, PONDOK INDAH 021-7657525| 021-7502324 Y Y ALL COVERAGE
Page 8 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
361 2379 KLINIK PRATAMA PALAPA DENTISTSJL. PALAPA I NO. 4 KOMPLEK PERTANIAN PASAR MINGGU
JAKARTA SELATAN 12520021-7806291| 021- 7806291 N Y DENTAL
362 3736 PRODIA KAMPUNG MELAYUJL. KH ABDULLAH SYAFEI NO. 28KEBON BARU, TEBET
JAKARTA SELATAN, 12830(021) 8308055, 8304268| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
363 4820 TIDI DENTAL CLINICJL. TEBET BARAT VII NO. 49 RT. 004 RW. 004, KEL. TEBET
BARAT KEC. TEBET, JAKARTA SELATAN(021) 8300050| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
364 3571 PRODIA BONA INDAHRUKO BONA INDAH BLOK A2/ KAV. C7, JL. KARANG
TENGAH RAYA LEBAK BULUS, JAKARTA 12440021-7506715| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
365 2641 KLINIK & APOTEK KF 42JL. ST. HASANUDDIN NO.1 KEBAYORAN BARU JAKARTA
SELATAN021 7220292| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
366 2800 KLINIK PERTAMEDIKA JAKARTA LAND (WTC)GED. WTC II LOWER GROUND FLOURJL. JEND SUDIRMAN
KAV. 29 JAKARTA SELATAN021-29522610| 021-29522611 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
367 2954 KLINIK AJI WARAS KARANG TENGAHJL. KARANG TENGAH RAYA NO.60, LEBAK BULUS,
CILANDAK, JAKARTA SELATAN 12440(021) 75909473| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
368 3326 KLINIK PERMATA MEDIKAJL. RAYA TANJUNG BARAT NO. 111 RT/RW 007/004, KEL.
TANJUNG BARAT, KEC. JAGAKARSA, JAKARTA SELATAN021-7821817| 021-7828489 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
369 2140KLINIK PERTAMEDIKA TUGU (pmc dental spa
& clinic)WISMA TUGU JL. HR. RASUNA SAID KAV. C8-9. 021-5200340| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
370 1712 KLINIK SUNFLOWER DENTAL & HEALTH CAREKOMP. BUMI KARANG INDAH JL.KARANG INDAH BLOK
A2/4, LOEBAK BULUS021-29203542/085100106511| 021-29203541 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
371 3710 THOMSON EXECUTIVE HEALTH CENTERTALAVERA SUITE, JL. TB.SIMATUPANG KAV. 22-26
JAKARTA SELATAN(021) 7592 5268| (021) 7592 5269 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
372 1488 RS. ASRI JL. DUREN TIGA RAYA, NO.20021 27837900 / 021-
7995566,7992211|02179198118/79198733 Y Y ALL COVERAGE
373 2874 LAB. PRODIA KEBAYORAN JL. GUNAWARMAN NO. 77, KEBAYORAN BARU 021-7220203| 021-7226450 N YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
374 2797 KLINIK PERTAMEDIKA PHE PHE TOWER LT. 2 JL. TB SIMATUPANG KAV. 99 021-29547300| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
375 1708 KLINIK PLAZA PT YPK MANDIRIPLAZA MANDIRI LT. BASEMENT I, JL. JEND GATOT
SUBROTO KAV 36-38021-5245351, 5245351| 021-5245351 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
376 1872 KLINIK TRIHATI PLUSRUKAN ROYAL PALACE BLOK A5, JL. PROF DR SOEPOMO
SH NO 1021-829 9119| 021-8299113 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
377 1942 KLINIK & APOTEK KF 47 JL. RADIO DALAM RAYA 1-5, JAKARTA SELATAN 021-7208735| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
378 1944 KLINIK & APOTEK KF 152 JL. RAYA PASAR MINGGU KM 18 JAKARTA SELATAN 0217943222| 021-7943223 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
379 1936 APOTIK FARMARIN VI RASAMALA WISMA PPBI JL. RASAMALA NO.2 PANCORAN 021-8290073| 021-83794460 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
380 2086 KLINIK GLOBAL DOCTOR JL. KEMANG RAYA NO. 87 JAKARTA SELATAN 021-7194565/ 7980183| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
381 2082 BRAWIJAYA CLINIC @ FX SUDIRMANFX SUDIRMAN LT 5 (F5) KAV. 8A-8B, JL. JEND SUDIRMAN
PINTU SATU SENAYAN JAKARTA021-25554156| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
382 2033 KLINIK NAMIRA JL. JATIPADANG RAYA NO. 62 PASAR MINGGU 021-7820645/78830676| 021-7820645 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
383 0228 RSIA. KEMANG MEDICAL CARE JL. AMPERA RAYA, NO.34,KEMANG021-27545454/27545400/021-
6317288|021-6317288021-78843548 Y Y ALL COVERAGE
384 2138 KLINIK PERTAMEDIKA PATRA JASAPATRA JASA OFFICE TOWER, JL. JEND. GATOT SUBROTO
KAV.32-34021-5228026/ 5217318| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
385 2139 KLINIK PERTAMEDIKA SINABUNGJL. SINABUNG II NO. 32 AF KEL. GUNUNG KEC. KEB. BARU
JAKARTA SELATAN021-7243262/7243282| 021-72800985 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
386 2229BRAWIJAYA CLINIC & LIFE STYLE @ OKTROI
KEMANG
OKTROI PLAZA, MEDICAL MEZZANINE LT. 3 JL. KEMANG
UTARA RAYA NO. 1 JAKARTA SELATAN021 - 7197580/ 71792101| 021 - 71792074 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
387 2443 BALI DENTAL CARE JL. PAKUBUWONO VI NO.111 JAKARTA SELATAN (021) 7223391/ 7223391| - N Y DENTAL
388 2341 KLINIK AJI WARAS CILANDAKJL. CILANDAK KKO NO.45A, RAGUNAN, PASAR MINGGU,
JAKARTA SELATAN 12550(021) 78836308; 78835703| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
389 0957 RSU. PETUKANGAN JL. CILEDUG RAYA NO.8A 021-7340906-|- 021-73889956 Y Y ALL COVERAGE
390 0972 RSU. AULIA JL. JERUK RAYA NO 15 JAGAKARS. A, JAKARTA SELATAN 021-7270208-|- 021-7866057 Y Y ALL COVERAGE
391 1412 APOTIK FARMARIN III BIDAKARAGED. BINASENTRA KOMP. BIDAKARA JL. GATOT
SOEBROTO KAV. 71 - 73 JAKARTA021 - 83785219| 021 - 83793006 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
392 1424 RSIA. ASIH JL. PANGLIMA POLIM I NO.34 JAKARTA SELATAN 12160 021-2700609-10| - Y Y ALL COVERAGE
393 1076 KLINIK YADIKA PETUKANGANJL. DAMAI RAYA NO.1 PETUKANGAN SELATAN - JAKARTA
SELATAN021-7370881-|- 021-73887810 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
394 1083 RS. MATA AINI JL. H.R.RASUNA SAID (KUNINGAN) JAKARTA021-5256228/5203866021-
5203866|021-5203866021-5224288/52964781 Y Y ALL COVERAGE
395 1546 KLINIK NDH (RAJA SERVICE) JL. RADIO DALAM RAYA, NO.54A 021-7257244| 021-7257244 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
396 1461 ALL CARE DENTAL CENTRE PLAZA 5 BLOK B NO.15 JL. MARGAGUNA PONDOK INDAH 72788688| 72788687 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
397 2174 SILOAM HOSPITALS SIMATUPANG JL. RA KARTINI NO.8 CILANDAK JAKARTA SELATAN, 12430 021 2953 1900 EXT 22601| 021 759 16997 Y Y ALL COVERAGE
398 0593 RS. SETIA MITRA JL. RS. FATMAWATI, NO.80-82, CILANDAK 021-7656000/7651021/7654676| 021-7656880/7656875 Y Y ALL COVERAGE
399 0854 RS. ZAHIRAH JL. SIRSAK NO.21, JAGAKARSA
021-
78888723/7872210/78888721021-
78888723|021-78888723
021-7270013/7872210 Y Y ALL COVERAGE
400 0795 RS. PUSAT PERTAMINA JL. KYAI MAJA 43, KEBAYORAN BARU (021) 7219555| (021) 7203540, Y Y ALL COVERAGE
401 0395 RS. PRIKASIH JL. RS. FATMAWATI, NO.74, PONDOK LAB. U - CILANDAK021-7501192/7504669/75901174021
- 7504669|021 - 7504669021-7505148 Y Y ALL COVERAGE
402 0879 RSU. YADIKA CIPUTAT JL. CIPUTAT RAYA, NO.5, KEBAYORAN LAMA 021-7291074| 021-72895046 Y Y ALL COVERAGE
403 1408 BIDAKARA MEDICAL CENTER (BIMC)GEDUNG BINA SENTRA, LT.DASAR, KOMP.BIDAKARA,
KAV.71-73, PANCORAN021-83783535/83783636| 021-83785349 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
404 5592 KLINIK THAMRIN TAMAN SARI
APARTEMEN TAMAN SARI SEMANGGI TOWER A UNIT GF.15
JL.AKRI NO.134 RT.008/002, KARET SEMANGGI,
SETIABUDI
(021) 29888506| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
405 2356MAYAPADA HOSPITAL JAKARTA SELATAN
(MHJS)JL. LEBAK BULUS I KAV. 29, JAKARTA SELATAN 021-29217777| 021-29216666 Y Y ALL COVERAGE
406 5413 KLINIK ROYAL HEALTH CARE JL. BUNCIT RAYA NO.99 KALIBATA, PANCORAN 021-7940015 / 0811935249| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
407 0796RS. METROPOLITAN MEDICAL CENTRE ( MMC
)JL. HR. RASUNA SAID, KAV. C21, KUNINGAN 021- 5203435/0811865958| 021-5226070/5227060 Y Y ALL COVERAGE
408 5428 GOOD DOCTORS MEDICAL CENTERKOMP.EPICENTRUM RASUNA, EPICENTRUM WALK OFFICE
SUITE LT.3 UNIT A 310-311021-29912131 - 32 / 29941137| 021-29941137 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
409 5429KLINIK UTAMA INDO MEDIKA
INTERNATIONAL
PLAZA OLEOS, JL.TB SIMATUPANG KAV.53A LG UNIT B,
KEL.KEBAGUSAN, KEC.PASAR MINGGU021-22780121 / 19| 021-22780120 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 9 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
410 3974 LAB. CITO JAKARTAJL. RS. FATMAWATI NO. 27 A, RT.001 RW.006 KEL.
GANDARIA SELATAN, CILANDAK, JAKSEL(021) 766 4036| (021) 766 3640 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
411 4234 RAYS INTERNATIONAL DENTAL CLINIC JL. BRAWIJAYA VIII NO. 2, JAKARTA SELATAN 021-7262347| 021-7225844 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
412 3989 KLINIK & APOTEK KF NO. 55 KEBAYORAN JL. KEBAYORAN LAMA NO. 34K JAKARTA SELATAN 021-7226444/7203563| 021-7203563 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
413 4640 KLINIK MOESLICHANJL. CIPETE NO. 3 RT/RW 014/003, KEL. CIPETE SELATAN,
KEC. CILANDAK, JAKARTA SELATAN(021) 7657861| (021) 75904535 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
414 4488 KLINIK UTAMA CIPUTRA SMG EYE CLINIC
LOTTE SHOPPING AVENUE FLOOR 5 CIPUTRA WORLD 1, JL.
PROF. DR. SATRIO KAV. 3-5, KEL. KARET KEC. SETIABUDI,
JAKARTA SELATAN
(021) 29888138| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
415 2798 INHOUSE KLINIK PERTAMEDIKA GARDA OTOKAWASAN PERKANTORAN ASS. ASTRA, JL. TB
SIMATUPANG KAV.15 JAKSEL021-75918577| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
416 0597 KLINIK JMC DHARMA BHAKTI JL. CILANDAK KKO RAYA NO.45 021-781 9848 / 0217989123| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
417 0758 DE BLITZR DENTAL CAREBellezza Shopping Arcade Lt.2 Unit 30&31 Jl.Letjen
Soepeno No.34 Arteri Permata Hijau JKT SELATAN 12210021-25675742| 021-25675743 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
418 2820 LAB. PRODIA ARTERIARTERI PONDOK INDAH, JL. SULTAN ISKANDAR MUDA
NO. 31 C, KEBAYORAN LAMA, JAKARTA SELATAN 12240(021) 7227728, 7226655, 7291710| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
419 2919 LAB. PRODIA PASAR MINGGU JL. RAYA PASAR MINGGU/ 98E, JAKARTA SELATAN 021-7986247/7901922/79184723| 021-7901922 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
420 2932 APOTEK KF55 CINEREPLN P3B JB KRUKUT-LIMO, CINERE 16514, KOTAK POS 159
CINERE JAKARTA SELATAN021 7220292| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
421 0110 RS. TRIA DIPA JL. RAYA PASAR MINGGU, NO.3A, PANCORAN 021-7993058,7974071-73| 021-7974074 Y Y ALL COVERAGE
422 4374 KLINIK MATA NUSANTARA (Lebak Bulus) JL. R.A. KARTINI NO. 99 LEBAK BULUS, JAKARTA 12440 (021) 751 6688| (021) 7519344 N Y GP,OP
423 3540 FHL DENTAL CLINIC EPPIWALK OFFICEEPPIWALK OFFICE SUITES LT. 6 UNIT B 629, JL. H.R.
RASUNA SAID KEL. KARET KUNINGAN KEC. SETIABUDI021-29912232| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
424 0842 BRAWIJAYA WOMEN & CHILDREN HOSPITAL JL. TAMAN BRAWIJAYA NO.1 CIPETE UTARA 021 - 7211337| 021 - 7211364 Y Y ALL COVERAGE
425 4707 KLINIK MAYAPADA
GD. MAYAPADA TOWER II LT. BASEMENT, JL. JEND.
SUDIRMAN KAV. 27, KEL. KARET, KEC. SETIABUDI
JAKARTA SELATAN
(021) 29859999 ext. 806| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
426 4210 RSIA. ANDHIKAJL. WARUNG SILA no. 8 RT. 006 RW. 04 GUDANG BARU,
CIGANJUR, JAGAKARSA, JAKARTA SELATAN
(021) 7863408; 78887087; 7874612;
7863408|(021) 7874612 Y Y ALL COVERAGE
427 3711 THOMSON MEDICAL CLINICPASIFC PLACE MALL, B1-01, JL. JEND SUDIRMAN KAV 52-
53 SCBD, JAKARTA SELATAN(021) 5797 3497| (021) 5797 3496 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
428 0999 RSU. MUHAMMADIYAH TAMAN PURING JL. GANDARIA I NO.20 KEBAYORAN BARU021-7229623/7250243/7208358|021-
7208358021-7234823/7210516 Y Y ALL COVERAGE
429 0797 RS. MEDISTRA JL. GATOT SUBROTO KAV.49 021-5210200| 021-5210184/5 Y Y ALL COVERAGE
430 4340 KLINIK EPICENTRUM MEDICAL CENTER
EPIWALK OFFICE SUITES LT. 3 UNIT B 316-317 KOMPLEK
RASUNA EPICENTRUM, JL. H.R RASUNA SAID KEL. KARET
KUNINGAN KEC. SETIABUDI,
(021) 2991 2383| (021) 2991 2393 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
431 4413 KLINIK UTAMA CIPUTRA MEDICAL CENTER
LOTTE SHOPPING AVENUE FLOOR 5 CIPUTRA WORLD 1, JL.
PROF. DR. SATRIO KAV. 3-5, KEL. KARET KEC. SETIABUDI,
JAKARTA SELATAN
021-29888137| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
432 4414AIC - MEDICAL IMAGING DIAGNOSTIC
CENTER
KUNINGAN CITY MALL B-C -D, JL. PROF SATRIO KAV. 18,
JAKARTA SELATAN 12940(021) 3005 1801/02| (021) 3005 1803 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
433 1066MRCCC-SILOAM HOSPITALS SEMANGGI (D/H
SPECIALIST C
JL. GARNISUN 2-3 KARET, SEMANGGI SETIABUDI
(BELAKANG UNIV. ATMAJAYA ) JAK- SEL021-29962888/800/788| 021-29962778 Y Y ALL COVERAGE
434 1752 LAB. KLINIK BIOTEST WIJAYA JL. WIJAYA I NO 58, KEBAYORAN BARU, JAK-SEL 021-7232445| 021-7268711 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
435 1836 AIS HEALTHCAREGEDUNG CITY PLAZA LT P9, JL. GATOT SUBROTO 42
(KAWASAN WISMA MULIA)021-29305480| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
436 4525 ALEA DENTAL CLINICJL. CIPETE RAYA NO. 16 BLOK A-7 RT.006/RW.004, KEL.
CIPETE SELATAN, CILANDAK, JAKARTA SELATAN(021) 75915723| - N Y DENTAL
JAKARTA TIMUR
437 1538 KLINIK MITRASANA (DANKOS FARMA)JL. RAWA GATEL, BLOK IIIS, KAV.37-38, KAW.INDUSTRI
PULO GADUNG4600158/4600157| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
438 1499 RB & KLINIK ANNISA CIRACAS JL. CIRACAS NO.18 021-87720807/87717636| 021-87717636 Y Y ALL COVERAGE
439 1490 RSIA. BUNDA ALIYAH JL. PAHLAWAN REVOLUSI NO.100 PONDOK BAMBU 021-86602525| 021-86600712 Y Y ALL COVERAGE
440 0060 RS. HARAPAN BUNDA JL. RAYA BOGOR KM.22 NO.44 021-8400257| 021-8412977/87780201 Y Y ALL COVERAGE
441 0888 RS. YADIKA PONDOK BAMBUJL. PAHLAWAN REVOLUSI NO.47 PONDOK BAMBU -
JAKARTA TIMUR
021-8615754 / 021-8610756|021-
8610756021-8613332 Y Y ALL COVERAGE
442 0289 RS. OMNI MEDICAL CENTER JL. PULO MAS BARAT VI, NO.20 021- 2977 9999| 021-4718081,4708180 Y Y ALL COVERAGE
443 0012RS. PREMIER JATINEGARA ( RS MITRA
INTERNASIONAL)JL. RAYA JATINEGARA TIMUR, NO.85-87 021-2800666/2800888|021-2800777 021-2800755 Y Y ALL COVERAGE
444 0122 RS. MEDIROS JL. PERINTIS KEMERDEKAAN, KAV.149
021-
4750042/4897415/4893036/4895817
/4721237021-4893036|021-4893036
021-4891937 Y Y ALL COVERAGE
445 0024 KLINIK PRIMA HUSADA CIBUBUR JL. LAPANGAN TEMBAK NO.2A CIBUBUR 021-87707503|021-9111938 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
446 0258 KLINIK DEVITA JL. JATINEGARA TIMUR NO.57 JATINEGARA0218501134/0218516274|021-819
6041021-85906901/8516274 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
447 0292 KLINIK PONDOK GEDE AGUNG JL. RAYA HANKAM, NO.58C-D, PONDOK GEDE 021-8464030| 021-8463803 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
448 0286 RS. KARTIKA PULO MAS JL. PULO MAS TIMUR K BLOK G-H-C/1 021-4703333|021-470 3333 021-4723402 Y Y ALL COVERAGE
449 0806 RS. HAJI JAKARTA JL. RAYA PONDOK GEDE(021) 8000693-95(021)
8000695|(021) 8000695021-80876175/8000152 Y Y ALL COVERAGE
450 0805 RSU. UKI JL. MAYJEN SOETOYO, CAWANG
021-
8092317,8010526,8092831,8010523
|
021-8092445/8005595 Y Y ALL COVERAGE
451 0807 KLINIK MHT TEGALAN JL. TEGALAN NO. 30 021-8581344| 021-8581344 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
452 0779 RS. AU DR.ESNAWAN ANTARIKSA JL. MERPATI NO.2 LANUD HALIM PERDANAKUSUMA (021) 8007027| (021) 8098 665 Y Y ALL COVERAGE
453 0382RB & KLINIK 24 JAM MHT PONDOK GEDE D/H
RS PONDOK GJL. RAYA PONDOK GEDE, NO. 23-25, KRAMAT JATI
021-8093602/80887175/74|021-
80887175021-80887174 Y Y ALL COVERAGE
454 0826 RB & KLINIK SEJAHTERA CIRACAS JL. RAYA CIRACAS NO.7021- 87717635/87712710/87712711-
|-021-87720232 Y Y ALL COVERAGE
455 1012 KLINIK IBIN SINA JL. PENDIDIKAN RAYA NO.33 DUREN SAWIT021- 866 03270, 866 1669021-
86603270|021-8660327086601611 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
456 0944RS. BHAYANGKARA TK.1 R.SAID SUKANTO
(POLRI)JL. RAYA KRAMAT JATI 021-8093288-|- 021-8094005 Y Y ALL COVERAGE
Page 10 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
457 0948 KLINIK SAPTA MITRA JALAN TAMAN MALAKA UTARA BLOK A12, MALAKAJAYA021-86906363/021-5844330|021-
5844330021-86906363 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
458 0099 RS. HARAPAN JAYAKARTA JL. BEKASI TIMUR RAYA, NO.6 KM.18, PULO GADUNG021-4603916/4601371/021-
46822879|021-46822879021-4608863 Y Y ALL COVERAGE
459 0386 RS. HERMINA JATINEGARA JL. RAYA JATINEGARA BARAT, NO.126021-8191223/021-8504371|021-
8504371021-8190111 Y Y ALL COVERAGE
460 1217 RSIA. RESTU KASIH JL. RAYA BOGOR, KM.19, NO.3A, KRAMAT JATI 021-8002166/8001177| 021-80882753 Y Y ALL COVERAGE
461 0102 RS. ISLAM JAKARTA TIMUR (PONDOK KOPI) JL. RAYA PONDOK KOPI021-8630654/8610471021-
8610471|021-8610471021-8611101 Y Y ALL COVERAGE
462 0749 RS. HARUM SISMA MEDIKA JL. TARUM BARAT, KALIMALANG JAKTIM021-8617212/3 ; 021-8617213|021-
8617213021-8601030 Y Y ALL COVERAGE
463 1706 RSU. PUSAT PERSAHABATAN JL. PERSAHABATAN RAYA NO. 1 JAKARTA TIMUR 021-4891708, 4891745| 2,147,112,224,890,770 Y Y ALL COVERAGE
464 2826 RS. COLUMBIA ASIA PULOMAS JL. KAYU PUTIH RAYA, PULOMAS - JAKARTA TIMUR 13210 (021) 29559400| (021) 2955 9477 Y Y ALL COVERAGE
465 0652 RB & KLINIK AL - FAUZAN JL. RAYA CONDET NO.13, BALEKAMBANG CONDET 021-80886224| 021-8096968 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
466 1139 KLINIK TJAKRA JL. RAYA BOGOR, KM.24, NO.35, SUSUKAN CIRACAS 021-8779 4539 / 8401677| 021-87794558/8401677 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
467 5540 KLINIK TERATAI PONDOK BAMBU
JL. PONDOK BAMBU BATAS NO. 14 RT. 003 RW. 02,
KEL.PONDOK BAMBU, KEC. DUREN SAWIT, JAKARTA
TIMUR
(021) 29361827| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
468 1933 APOTIK FARMARIN II PENGGILINGANPERUM TAMAN PULO INDAH BLOK I NO.7-8 PENGGILINGAN
CAKUNG021-4800688| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
469 1843 RSIA. SAYYIDAHJL. TAMAN MALAKA SELATAN NO. 6 PONDOK KELAPA,
JAKARTA TIMUR(021) 8690 2950| (021) 864 9886 Y Y ALL COVERAGE
470 4157 KLINIK CEMPAKA JL. RAYA PULAU GEBANG NO. 86 RT 06 RW 06, CAKUNG 021- 480 1980| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
471 2142 KLINIK PERTAMEDIKA RAWAMANGUN JL. MUNDU RAYA NO.1 JAKARTA TIMUR 021-4894150| 021-4894278 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
472 1244 RS. MASMITRA JL. KELURAHAN JATIMAKMUR, NO.40, PONDOK GEDE 021-84971766| 021-8483047 Y Y ALL COVERAGE
473 3533 KLINIK MEDIKA PRAKARSA JL. RADEN INTEN II DUREN SAWIT, JAKARTA TIMUR (021) 86908103| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
474 4376 KLINIK MATA NUSANTARA (DEWI SARTIKA)GD. ALHIJAZ, JL. DEWI SARTIKA 293A, CAWANG, KEC.
KRAMAT JATI, JAKARTA TIMUR(021) 8087 8833| (021) 8087 7474 N Y GP,OP
475 4356 KLINIK BUDHI PRATAMABPRI CENTER GED. B, JL. RAYA TENGAH NO.26 GEDONG,
PASAR REBO, JAKARTA TIMUR(021) 87783668| (021) 87782670 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
476 4431 RS. PUSAT OTAK NASIONAL JL. M.T HARYONO, CAWANG, JAKARTA TIMUR 13630 (021) 2937 3377| (021) 2937 3445; 293 Y Y ALL COVERAGE
477 2620 KLINIK & APOTEK KF 4 JL. PERSERIKATAN 7-8, RAWAMANGUN 021 471-8059| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
478 2638 KLINIK & APOTEK KF 147 JL. DUREN SAWIT 021 861-5458| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
479 1080 RS. KESDAM CIJANTUNGJL. MAHONI NO.1, CIJANGTUNG II PASAR REBO JAKARTA
TIMUR021-8407886/8400535/87793332-|- 021-87793332 Y Y ALL COVERAGE
480 2643 KLINIK & APOTEK KF 49 JL. P. REVOLUSI 53, PD. BAMBU, JAKARTA TIMUR 021 861-5154| 021-8612721 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
481 3980 KLINIK & APOTEK KF 48 JL. MATRAMAN RAYA NO 55 JAKARTA TIMUR 0818810414| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
482 3981 KLINIK & APOTEK KF LAP.TEMBAK JL. LAWU B1 NO.1 CIBUBUR LAPANGAN TEMBAK CIBUBUR 08128737346| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
483 1868RSIA. AL-FAUZAN (JAKARTA ISLAMIC
HOSPITAL)
JL. PEDATI NO 3 RT 5 RW 7, KAMPUNG TENGAH KRAMAT
JATI021-87780318| - Y Y ALL COVERAGE
484 1907 RSIA. SAMMARIE BASRAJL. BASUKI RACHMAT NO. 31, PONDOK BAMBU, DUREN
SAWIT021-86613145| 021-86613147 Y Y ALL COVERAGE
485 3531 SUMATERA EYE CENTER JAKARTA JL. PEMUDA NO. 36, RAWAMANGUN, JAKARTA TIMUR (021) 4714848| (021) 4755703 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
486 1932 APOTEK KIMIA FARMA 193 JL. UTAN KAYU NO 105 P JAKARTA TIMUR 021-8520808| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
487 2251 RS. ANTAM MEDIKA JL. PEMUDA RAYA NO 1A PULOGADUNG JAKARTA TIMUR 021- 29378939/40/44| 021- 29385160 Y Y ALL COVERAGE
488 2141 KLINIK PERTAMEDIKA MEDAN SATRIAJL. ARUN IX NO. 2 MEDAN SATRIA CAKUNG JAKARTA
TIMUR 17132021-4604944| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
489 2391 RS. JANTUNG JAKARTA JL. MATRAMAN RAYA NO.23, JAKARTA TIMUR 021-29361158/29361160/29360698| 2129361158 Y Y ALL COVERAGE
490 2375 KLINIK NAMIERA JL. KELAPA DUA WETAN PERUM PTB BLOK 2C NO 10 021-8725774| 021-8725774 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
491 1001 RS. DHARMA NUGRAHA JL. BALAI PUSTAKA BARU NO.19 RAWAMANGUN021-4707433-37021-4707437|021-
4707437021-4707429/8 Y Y ALL COVERAGE
492 1192 KLINIK & APOTEK PUTEWA JL. NUSA INDAH RAYA BLOK 40 NO.17H 021-8622207/70302043| 021-8622207 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
493 0962 KLINIK CONDET JAYA JL. CONDET JAYA NO.18 BATU AMPAR 021-8090712|- 021-80881275 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
494 0990RS. JANTUNG BINA WALUYA CARDIAC
CENTERJL. TB SIMATUPANG NO.71
021-87781605-06021-87781606|021-
87781606021-8403869 Y Y ALL COVERAGE
495 1110 RSIA. RESTI MULYAJL. PAHLAWAN KOMARUDIN RAYA NO. 5 PENGGILINGAN
CAKUNG021-4803936-4802192-4803707| 021-48701488 Y Y ALL COVERAGE
496 1096 KLINIK YADIKA CIBUBUR JL. LAPANGAN TEMBAK NO.9 PEKAYON-CIBUBUR 021-8711515-|- 021-8711515 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
497 1258 KLINIK SUCI HUSADA JL. SUCI NO.21 RT.08/06 SUSUKAN - CIRACAS 021- 87798796| 021- 87798796 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
498 1262 RS. RAWAMANGUN JL. BALAI PUSTAKA RAYA, NO.29-31 021-4893531| 021-4710918 Y Y ALL COVERAGE
JAKARTA UTARA
499 4377KLINIK MATA NUSANTARA (PANTAI INDAH
KAPUK)
RS. PANTAI INDAH KAPUK LT.8, JL. PANTAI INDAH UTARA
NO. 3, KEL. KAPUK MUARA, PENJARINGAN, JAKARTA
UTARA
(021) 5595 8236| (021) 5595 8393 N Y GP,OP
500 0919 RS. PELABUHAN JAKARTA JL. KRAMAT JAYA, TANJUNG PRIOK 021-4403026|021-4403026 021-4403551/4406886 Y Y ALL COVERAGE
501 0170 RS. PLUIT JL. RAYA PLUIT SELATAN, NO. 2021-6685006; 021-668507|021-
668507021-6684878 Y Y ALL COVERAGE
502 3998 KLINIK PESONA TANAH PASIRJL. TANAH PASIR RUSUN PENJARINGAN BLOK MAWAR I A
KEL.PENJARINGAN,KEC.PENJARINGAN, JAKARTA UTARA021-66675691/085101280470| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
503 2143 KLINIK PERTAMEDIKA DELI JL. DELI NO. 22 JAKARTA UTARA - 1-628 021-43923390 / 3389| 021-4353461 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
504 0882 RS. ISLAM JAKARTA UTARA ( SUKAPURA ) JL. TIPAR CAKUNG NO.5 JAKARTA UTARA021-4400781,4400778021-
4400778|021-4400778021-44832228,4400782 Y Y ALL COVERAGE
505 4733 CLINIC PROTERAKIRANA BOUTIQUE OFFICE F2 NO. 1-2, KELAPA GADING,
JAKARTA 14240(021) 29365237| (021) 2936 5242 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 11 of 40
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
506 4079 RS. DUTA INDAH JL. TELUK GONG RAYA NO 12 (021) 666 7 6188| (021) 6667 6190 Y Y ALL COVERAGE
507 4513 PRODIA PANTAI INDAH KAPUK RUKAN GOLD COAST B3-B3 021-29032788-99| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
508 3732 PRODIA SUNTERJL. DANAU SUNTER UTARA BLOK C1 NO. 14, SUNTER
AGUNG - JAKARTA UTARA 14350-| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
509 3733 PRODIA PLUIT-KOMP. RUKO SENTRA BISNIS PLUIT, JL. PLUIT SAKTI
RAYA NO. 28 A BLOK A-6, JAKARTA UTARA 14440(021) 66603561, 66600571| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
510 3734 PRODIA KELAPA GADINGJL. BOULEVARD RAYA BLOK H 4 NO. 15, KELAPA GADING
PERMAI, JAKARTA UTARA 14240(021) 4522148| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
511 2458 RSIA. GRAND FAMILYJL. PANTAI INDAH SELATAN 1, KOMPLEK ELANG LAUT
BOULEVARD KAV.1 NO.1, PENJARINGAN - JAKARTA UTARA
021-296333777/02129673737 DAN
29678062|- Y Y ALL COVERAGE
512 2506 MITRASANA KELAPA GADING
JL. BOULEVARD TIMUR RAYA BLOK NB I NO 36
KELURAHAN PEGANGSAAN DUA, KELAPA GADING JAKARTA
UTARA
021-36464908/4585455| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
513 0748 RS. GADING PLUITJL. BOULEVARD TIMUR RAYA, KELAPA GADING. JAKARTA
UTARA
021-4521001/4520201021-
4520201|021-4520201021-4520390 Y Y ALL COVERAGE
514 1677 KLINIK SOLA GRACIA MEDICAL CENTER JL. SUNTER AGUNG UTARA BLOK A 17 D NO 1 021-6459530/6452041| 021-6459530; 6451274 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
515 1746 LAB. KLINIK BIOTEST PLUIT JL. PLUIT SAKTI RAYA NO 25 JAKARTA UTARA 021-6622611| 021-6628166 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
516 1644 KLINIK SYIFA MEDICAL CENTRE JL. LONTAR LUAR NO.7 RT 004/04 TUGU UTARA KOJA 021-43935260| 021-43935375 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
517 1813 FRIENDLY DENTAL CARE JL. DANAU SUNTER UTARA BLOK C1 / 4 B JAKARTA UTARA 021-65836485| 021-65836484N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
518 1946 APOTEK KIMIA FARMA 46 JL. RAWA BADAK NO. 3, KOJA, JAKARTA UTARA 021-4393397| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
519 2144 KLINIK PERTAMEDIKA YOS SUDARSO JL. YOS SUDARS. O NO. 34 JAKARTA UTARA - 1-628 021-43928260| 021-43908706 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
520 2412 KLINIK BERSALIN LESTARIJL. MANGGAR NO.141 KEL.LAGOA, KEC.KOJA TANJUNG
PRIOK JAKARTA UTARA021 43922950| - N Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
521 0587 RS. SATYA NEGARA JL. AGUNG UTARA RAYA, BLOK A, NO.1021-64715200/021-687813-
14/6|021-687813-14/6021-6877813 Y Y ALL COVERAGE
522 1263 KLINIK SEMPER SISMA MEDIKA JL. KESEMEK, NO.3-5, SEMPER BARAT, CILINCING 021- 4400902/4403101| 021-4403101 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
523 1269 RS. MULYASARI JL. RAYA PLUMPANG SEMPER NO. 19 JAKARTA UTARA 021-43931111-43936666-43939999| 021-43934369/8888 Y Y ALL COVERAGE
524 1422 ROYAL PROGRESS INT HOSPITAL JL. DANAU SUNTER UTARA, SUNTER PARADISE I 021- 6400261; 6459877| 021-6519534 Y Y ALL COVERAGE
525 0186 RS. MITRA KELUARGA KELAPA GADING JL. BUKIT GADING RAYA KAV.2 KELAPA GADING PERMAI 021-45852700| 021-45852727/4585404 Y Y ALL COVERAGE
526 0812 RS. ATMA JAYA JL. PLUIT RAYA NO.2 (021) 6606127| (021) 6606122 Y Y ALL COVERAGE
527 0811 RS. SUKMUL JL. TAWES NO.18 - 20, TANJUNG PRIOK 021- 4301269| 021- 4301272 Y Y ALL COVERAGE
528 0396 RS. PANTAI INDAH KAPUK JL. PANTAI INDAH UTARA 3, PANTAI INDAH KAPUK 021-5885066; 5885065| 021-5880910/5881091 Y Y ALL COVERAGE
529 0910 KLINIK GADING UTAMA JL. KELAPA GADING BOULEVARD CN 2/25021-4532493/021-4532494021-
4532494|021-4532494021-4521933 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
530 0876 RSIA. FAMILYJL. PLUIT MAS I BLOK A NO.2A-5A, KOMPLEK PERUMAHAN
PLUIT MAS, JAKARTA UTARA
021-6695066/6694990021-
6694990|021-6694990021-6615563/66607254 Y Y ALL COVERAGE
531 1033 RS. PORT MEDICAL CENTER JL. ENGGANO NO.10 TANJUNG PRIOK 021-43902350/43902351-|- 021-43902302 Y Y ALL COVERAGE
GORONTALO
GORONTALO
532 3731 PRODIA GORONTALOJL. NANI WARTABONE, GORONTALO (EKS JL. DI
PANJAITAN NO. 27, GORONTALO 96115)(0435) 826246| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
533 1513 RSU. BUNDA GORONTALO JL. HB.JASSIN, NO.269, KOTA GORONTALO 0435-830600/827573/829290| 0435-827573 Y N H&S,MAT
534 1420 RSIA. SITTI KHODIJAH GORONTALO JL. NANI WARTABONE NO. 101 d/h JL. AHMAD YANI0435-822130/0435-821253/0435-
824410|0435-824410 Y N ALL COVERAGE
JAMBI
JAMBI
535 2184 APOTEK KIMIA FARMA 208 JL. SOEMANTRI BROJONEGORO NO. 108877800501/082146383275/07417
078571|- N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
536 0894SILOAM HOSPITALS JAMBI (D/H RS. ASIA
MEDIKA)JL. SOEKARNO - HATTA, PAALMERAH JAMBI 0741-5919000-|- 0741-573271/573238 Y Y ALL COVERAGE
537 3570 PRODIA JAMBI JL. URIP SUMOHARDJO 2-3, TELANAI PURA, JAMBI 0741) 64688,| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
538 2047 RSIA. ANNISA JAMBIJL. KABIA NO 04 RT 01 KEL. KEBUN HANDIL KEC
JELUTUNG KOTA JAMBI(0741) 445226| - Y Y ALL COVERAGE
539 2207 RSU. BAITURRAHIM JAMBI JL. PROF. M. YAMIN SH NO. 30 LEBAK BANDUNG - JAMBI 0741-35165/0741-5911096/97/98| 0741-5911099/97 Y Y ALL COVERAGE
540 2644 KLINIK & APOTEK KF 299 JL. R.MATTAHER NO.40, RAWASARI, JAMBI 0741 25635| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
541 0550 RS. ST.THERESIA JL. SUTOMO, NO.19 0741 - 23119 / 7553811| 0741-20832 Y Y ALL COVERAGE
MUARA BUNGO
542 1926 RS. SENTRAL MEDIKA MUARA BUNGO JL. RANGKAYO HITAM, CADIKA MUARA BUNGO, JAMBI 0747-22207/22209| 0747-22209 Y Y ALL COVERAGE
JAWA BARAT
BANDUNG
543 4518 PRODIA BANJARAN JL. PAJAGALAN NO. 10 BANJARAN 022-5946190| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
544 2936 LAB. PRODIA BUMI MAS KENCANARUKO BUMI MAS KENCANA, JL. AH. NASUTION 928 B
CIKADUT BANDUNG022-7236559| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
545 3366 SANTOSA HOSPITAL BANDUNG KOPO JL. K.H. WAHID HASYIM (KOPO), NO.461-463 BANDUNG 022-54280333| 022-5402242/54280365 Y Y ALL COVERAGE
546 3560 LAB. PRODIA BUAH BATU JL. BUAH BATU NO. 160, BANDUNG 40265 (022) 7310128| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 12 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
547 0761 RS. SANTO BORROMEUS BANDUNGJL. IR. H. JUANDA NO. 100 LEBAK GEDE COBLONG
BANDUNG JAWA BARAT, INDONESIA
022 2552000/022-2552083/95022-
2552003|022-2552003022-2504235 Y Y ALL COVERAGE
548 4116 LAB. PRODIA KURDI JL. MOH TOHA NO. 126 BANDUNG (022) 5206492| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
549 5119 KLINIK BRAWIJAYA BANDUNG JL. KH. ACHMAD BAHLAN NO. 40, BUAH BATU, BANDUNG 022- 7308104| (022) 7311484 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
550 1125 RS. CAHYA KAWALUYAN JL. PARAHYANGAN KM.3 KAV.HOS PADALARANG 022-6803700| 022-6803711/6803730 Y Y ALL COVERAGE
551 4123 LAB. PRODIA MTCMETRO INDAH MALL BLOK B NO.5, JL. SOEKARNO HATTA,
BANDUNG022-7536256| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
552 4124 LAB. PRODIA PASIRKALIKI JL. PASIRKALIKI NO. 225, BANDUNG 022-2034685| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
553 3001 LAB. KLINIK BIOTEST NARIPAN JL. NARIPAN NO. 41 BANDUNG (022) 4205544| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
554 4682 BANDUNG EYE CENTERJL. SUMATERA KEBON PISANG, KEC. SUMUR BANDUNG,
BANDUNG(022) 4214390| - N Y ALL COVERAGE
555 4967 RSKIA. HARAPAN BUNDA BANDUNGJL. PLUTO RAYA BLOK C RT. 01 RW. 02, KEL. MARGASARI
KEC. BUAHBATU, BANDUNG 40286(022) 7506490| (022) 7514712 Y Y ALL COVERAGE
556 3588 KIMIA FARMA SINDANGLAYA JL. AH.NASUTION NO.126 B BANDUNG 022-7278664| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
557 3678 PRODIA KOPO JL. KOPO PERMAI I BLOK 55 A / 6, BANDUNG 40227 (022) 5404291| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
558 0044 RSU. HERMINA PASTEUR JL. DR. DJUNDJUNAN, NO.107, PASTEUR 022-6072525| 022-6037815 Y Y ALL COVERAGE
559 2950 RS. KB. MELINDA IIJL. CIPTO NO. 1 RT 05/02, KEL. PASIRKALI KEC.
CICENDO, KOTA BANDUNG022-4267888/4233777| 022-4247888 Y Y ALL COVERAGE
560 3589 KIMIA FARMA 319 METRO JL. VENUS RAYA NO 27 0227564623| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
561 3591 APOTEK KIMIA FARMA 381 KOPO JL. KOPO CIRANGRANG NO.638 BANDUNG 022-5436596 / 085721647451| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
562 3592 KIMIA FARMA SETIABUDI JL. DR.SETIABUDHI NO 36, BANDUNG 022-2038048 / 0821200770017| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
563 4986 RSGM. MARANATHAJL. PROF. DRG. SURYA SOEMANTRI NO. 65, RT. 01, RW.
04, KEL. SUKAWARNA, KEC. SUKAJADI(022) 2005936| (022) 2019571 N Y ALL COVERAGE
564 1169 RS. AMC (ANNISA MEDICAL CENTER) JL. RAYA CILEUNYI RANCAEKEK 022-7781630,70804777,70805777| 022-70804777/7781629 Y Y ALL COVERAGE
565 1171SANTOSA BANDUNG INTERNASIONAL
HOSPITALJL. KEBON JATI, NO.38 022-4248333| 022-4211086/84468598 Y Y ALL COVERAGE
566 0958 KLINIK AN-NUR JL. DR. SETIA BUDI NO.63 022-2031922-|- 022-2031922/2042213 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
567 0959 KLINIK ASRI HUSADA I JL. BEKAMIN NO.18 022-7230425-87245792|- 022-2507293 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
568 1088 RS. RAJAWALI JL. RAJAWALI NO.38022-6031087, 6011913,
6079143,6051087-|-022-6032077 Y Y ALL COVERAGE
569 1093 RS. KHUSUS BEDAH HALMAHERA SIAGA JL. LL.RE MARTADINATA NO.28 022-4206061/70858254/4216436-|- 022-4236920 Y Y ALL COVERAGE
570 1265 APOTEK KIMIA FARMA SULAJANA (KF 51) JL. SULAJANA NO. 24 022-91512935| 022-4261088 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
571 0145 RS. MUHAMMADIYAH BANDUNG JL. KH. AHMAD DAHLAN NO.53
022-
7301062,7312167,7323549,7306935
,7323548|
022-7306458 Y Y ALL COVERAGE
572 0886 RSUD. AL IHSAN JL. KIASTRAMANGALA, BALEENDAH,
022-
5940872/5941719/5941729/5940770
/87799431|022-5941719
022-5941709 Y Y ALL COVERAGE
573 1900 TELEMEDIKA HEALTH CENTER (THC) SENTOT JL. SENTOT ALIBASYAH NO 4 BANDUNG 022-61115555| .N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
574 1515 RSIA .MELINDA JL. PAJAJARAN, NO.46
022-
4222788,4222388,4209088,4266700
|
022-4215700 Y Y ALL COVERAGE
575 1568 KLINIK UTAMA MONALISA JL. MOCH. RAMDHAN NO.32 022-5211311| 022-5200162 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
576 2719 KLINIK JAYA SENTOSA JL. SUNDA NO.75, BANDUNG 022 426 4258| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
577 2720 KLINIK JAYA ABADI ( GROUP JAYA SENTOSA) JL. BUAHBATU NO.245 , BANDUNG (022) 7317779| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
578 0303 RS. ADVENT BANDUNG JL. CIHAMPELAS, NO.161 022 -2034386-9/2034388| 022-2043167/2041109 Y Y ALL COVERAGE
579 1170 RS. SANTO YUSUP JL. CIKUTRA 7 BANDUNG 022-7208172,022-7217097, 022-7217103, 022-7231721|022-7202419 Y N H&S,MAT
580 2163 LAB. PRODIA BANDUNG JL. WASTUKENCANA NO.38 BANDUNG 022-4222541| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
581 2167 APOTEK FARMARIN BANDUNG 2 TUBISJL. TUBAGUS ISMAIL NO.79 RT/RW 004/012 KEL.SEKELOA
KEC. COBLONG BANDUNG022-2500387| 022-2517116 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
582 1578 RS. HERMINA ARCAMANIK JL. AH.NASUTION, KM.7, NO.50, ARCAMANIK BANDUNG 022-87242525| 022-7271771 Y Y ALL COVERAGE
583 1087 RS. BUNGSU JL. VETERAN, NO.6 022-4231550-|- 022-4231582 Y Y ALL COVERAGE
584 0144 RS. IMMANUEL BANDUNG JL. KOPPO, NO.161022-5201051/5201672/5224216022-
5224216|022-5224216022-5224219 Y Y ALL COVERAGE
585 1687 RS. IMCJL.RAYA CIMAREME NO.170-173 NGAMPRAH,
PADALARANG, BANDUNG BARAT022-6620923/6620965| 022 - 6620964 Y Y ALL COVERAGE
586 4237 RSIA. GRHA BUNDA JL. TERUSAN JAKARTA NO. 15-17 BANDUNG, JAWA BARAT 022-872 56789| 022-872 56000 Y Y ALL COVERAGE
587 2625 KLINIK & APOTEK KF 12 JL. IR H JUANDA NO1 BANDUNG 022 4205421| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
588 2626 KLINIK & APOTEK KF 14 JL. CIAMPELAS 7, BANDUNG 022-4201596| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
589 2622 KLINIK UTAMA AL-ISLAM JL. AWIBITUNG NO.29 CICADAS BANDUNG 40121 (022) 7208284| (022) 7276149 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
590 2734 RSU. PINDADJL. JEND. GATOT SUBROTO NO.517 (PAPANGGUNAN)
BANDUNG 40285022-7322877/7309807| 022-7322468 Y Y ALL COVERAGE
591 2730 KLINIK & APOTIK K-24 JL. LASWI NO.1A,BANDUNG (022) 7821700/7215992| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
592 2704 KLINIK & APOTEK KF 43 JL. BUAH BATU, BANDUNG 022 7305019| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
593 2705 KLINIK & APOTEK KF 320 JL. CINUNUK NO.192, BANDUNG 022 7801875| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
594 1211 KLINIK ASRI HUSADA II JL. TITIRAN NO.16 022-2507293| 022-2507293 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 13 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
595 1829 RSIA. LIMIJATI JL. LAKS L RE MARTADINATA 33-39022-4207770/022-
84281333/84469472|0224-4260956 Y Y ALL COVERAGE
596 4517 PRODIA MAJALAYA JL. BABAKAN NO.60 MAJALAYA 022-5952724| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BANJAR
597 4122 LAB. PRODIA BANJAR JL. STADION PATROMAN KAV III NO. 3 0265-2732534| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BEKASI
598 0294KLINIK KARYA MEDIKA III (APOTIK MEKAR
ASRI)JL. PERJUANGAN, NO.30C, TELUK BUYUNG 021-8851152| 021-8851152 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
599 0819 RB & KLINIK PERMATA BUNDA SETU PERUM GRAHA MUSTIKA MEDIA, BLOK A5, NO.15, SETU 82611729 / 88328001| 82611729 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
600 0873 APOTIK & KLINIK LEGENDA SEHAT JL. ZAMRUD UTARA BLOK U16 NO.100 KOTA LEGENDA 021-82600148| 021-82606179 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
601 1013 RSIA SELASIH MEDIKA JL. RAYA BINTARA NO 5, BEKASI BARAT 021-8850155| - Y Y ALL COVERAGE
602 1038 KLINIK HARAPAN SEHAT IIIPERUMAHAN VILLA MUTIARA JAYA, BLOK MB 16/7,
CIBITUNG021- 68295994/88393875-|- - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
603 1053 RS. ST. ELISABETH - BEKASI JL. RAYA NAROGONG NO.202 KEMANG PRATAMA
021-
82430101/82400186/8229767021-
82432082|021-82432082
021-82432083 Y Y ALL COVERAGE
604 0622 RSU. MITRA MEDIKA
JL. DESA JATIWANGI-CIKEDOKAN/SEBELAH SELATAN
KAWASAN MM 2100 KP KAMURANG RT 1/1 CIKEDOKAN,
CIKARANG BARAT
021-8998
3741/71691709/98213879|021-89983575 Y Y ALL COVERAGE
605 0588 KLINIK MELVIANA JL. SAPARUA RAYA NO.239 - 240 PERUMNAS III BEKASI 021 - 88354744| 021-88341291 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
606 0036 RS. SENTOSA JL. PAHLAWAN, NO.60 DUREN JAYA, BEKASI TIMUR 021-880 6140| 021-881 4950 Y Y ALL COVERAGE
607 0324 RS. GRAHA JUANDA JL. IR. H. JUANDA, NO.326021- 8811832, 8821004,
8811832,88346880|021- 8811832021 - 88346880 Y Y ALL COVERAGE
608 1140 RS. RAWA LUMBU JL. DASA DARMA, NO.20-23, RAWA LUMBU 021-82422511| 021-82432958 Y Y ALL COVERAGE
609 0982 RS. BUDI LESTARIJL. KH.NOER ALIE, NO.2 DEPAN PERUMNAS II,
KALIMALANG
021-8842336/8893486021-
8893486|021-8893486021-8893487 Y Y ALL COVERAGE
610 0987 RB & KLINIK HARAPAN SEHAT CIBITUNG JL. TEUKU UMAR NO.33 CIBITUNG 021-88336674-|- 021-8901126 Y Y ALL COVERAGE
611 0988 RS. PERMATA BUNDA BEKASI PERUM GRAMAPURI TAMANSARI C1/8-10 CIBITUNG 021-88328001/88392537-|- 88328002 Y Y ALL COVERAGE
612 1120 KLINIK PURI NUSAPHALA JL. CITRA INDAH A/14 PERUM PURI NUSAPALA JATI ASIH 021-82440368/7| 021-82440368 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
613 1207 KLINIK DIPONEGORO JL. DIPONEGORO NO.26 TAMBUN 021 - 8817062| 021-88346743 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
614 1216 RS. JUWITA JL. M. HASIBUAN NO.78 - BEKASI 021 -8829590/1| 021-8829592 Y Y ALL COVERAGE
615 1136 KLINIK PERMATA BUNDA BEKASIJL. BOSIH RAYA RUKO KARTIKA WANASARI BLOK.C1/4
CIBITUNG
021- 88373158 / 021-88328001/
88392537|- N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
616 1090 RS. PERMATA CIBUBUR JL. ALTERNATIF CIBUBUR - CILEUNGSI NO.6A BEKASI 021-8458806-|- 021-84592146 Y Y ALL COVERAGE
617 1259 KLINIK WIJAYA KESUMA JL. NAROGONG SAKTI RAYA BLOK A 20 NO.1 021 - 8210779| 021 - 8226455 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
618 0010 RS. MITRA KELUARGA BEKASI BARAT JL. JEND. A.YANI, BEKASI BARAT 021-8853333| 021-8842550/8855000 Y Y ALL COVERAGE
619 0032 RB. BUNDA AUNI VILLA NUSA INDAH, BLOK D5, NO.19 021-82402286/82420366/82403873| 021-82410136 Y Y ALL COVERAGE
620 0409 KLINIK DHARMA MEDIKA JL. PEMUDA, NO.33, KRANJI 021-8855173,8866711| 021-8866711 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
621 0185 RS. BHAKTI KARTINI JL. KARTINI, NO.11 021-8801954/88348492| 021-8824228 Y Y ALL COVERAGE
622 0767 KLINIK MHT BEKASI JL. H.M JOYO MARTONO NO.31B BEKASI TIMUR 021-8814262| 021-8814262 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
623 0620 RS. KARYA MEDIKA II (D/H RSIA. ) JL. SULTAN HASANUDIN NO.63 TAMBUN021-883 24366; 70934766/ 021-
88361980|021-88361980021-88327514 Y Y ALL COVERAGE
624 0766 RS. ANANDA BEKASI JL. SULTAN AGUNG NO.17, MEDAN SATRIA BEKASI 021-8854338| 021- 88950141 Y Y ALL COVERAGE
625 0410 RS. BELLA JL. IR. JUANDA, NO.141021-880 1775/ 880177/8819377021-
880177|021- 88017702188342438/88352506 Y Y ALL COVERAGE
626 0384 RS. MEKAR SARI JL. MEKAR SARI, NO.1021-8802641,8813787021-
8813787|021-8813787021-8810055/88350908 Y Y ALL COVERAGE
627 0250 KLINIK KARYA MEDIKA I JL. IR H JUANDA NO.38 C021-8801293021-8800381|021-
8800381021-8816137 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
628 0188KLINIK FAJAR MEDIKA ( GROUP KARYA
MEDIKA )RUKO KAWASAN INDUSTRI MM2100, CIBITUNG 021-8981162| 021-8981162 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
629 0715 KLINIK MUTIARA I (CITRA HUSADA I) PERUM METLAND JL. KALIMAYA 6 BLOK L2 / 1 BEKASI 021-29487893| 021-88337919 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
630 1771 RS. KARTIKA HUSADA SETUJL. BURANGKENG RT 01/06 DESA BURANGKENG SETU
BEKASI021-82610003/4| 021- 82610005 Y Y ALL COVERAGE
631 1807 RS. TIARA BEKASIJL. RAYA BABELAN NO. 63 KEL. KEBALEN KEC. BABELAN
KAB. BEKASI021-89131111/021-89133333| 021-89132039 Y Y ALL COVERAGE
632 1486RS. AWAL BROS BEKASI (D/H RS. GLOBAL
AWAL BROS )JL. KH.NOER ALI KAV.17-18 KALIMALANG 021-8868888/88855333| 02188855222/88855210 Y Y ALL COVERAGE
633 1816 RS. HARAPAN MULIAJL. RAYA CIBARUSAH NO. 5 KB. KOPI, CIBARUSAH JAYA
KAB. BEKASI021-89952340| 021-89952460 Y Y ALL COVERAGE
634 1830 RB & KLINIK AMIRA CIKARANG JL. RAYA BY PASS LEMAH ABANG, CIKARANG TIMUR 021-8914 2719| 021-89142719 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
635 1937 APOTIK FARMARIN VII BEKASI
JL. GURAME RAYA PERTOKOAN KAV.29 PERUMNAS KAV.29
PERUMNAS II KEL, KAYU RINGIN RAYA KEC BEKASI
SELATAN.
02188968419| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
636 1924 KLINIK MANDIRIPERUM VILLA MUTIARA CIKARANG BLOK R 26-27
CIKARANG SELATAN021-897 4883| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
637 1417 RSIA. RINOVA INTAN JL. RAYA SEROJA NO.101 021-8849401| 021-8848739 Y Y ALL COVERAGE
638 1203 KLINIK SEHAT SEJAHTERA I JL. RAYA NUSANTARA NO.2 PERUMNAS III BEKASI TIMUR 021-88349427| 88349427 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
639 1517 RSU. DR. ADAM TALIB JL. TEUKU UMAR, NO.25, CIBITUNG 021-88332305/06| 021-88332308 Y Y ALL COVERAGE
640 1277 RB & KLINIK GUCI MEDIKA JL. PRAMUKA NO.79 RAWA LUMBU 021-82433158| 021-8221921 Y Y ALL COVERAGE
641 1293 KLINIK YAKESTI BEKASI JL. RAYA NAROGONG KM.7 NO.45 BOJONG MENTENG -021 8253516| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
642 1296 RSB. TAMAN HARAPAN BARUJL. TAMAN HARAPAN BARU RAYA, BLOK R-
I,NO.20,PEJUANG MEDAN SATRIA021-88871202| 021- 88871203 Y Y ALL COVERAGE
643 1304 RSIA. PUSPA HUSADAJL. RAYA PONDOK TIMUR KM. 1, NO 27 JATIMULYA
TAMBUN SELATAN-BEKASI021-82618978/82618979| 021-82618977 Y Y ALL COVERAGE
Page 14 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
644 1530 KLINIK SIERRA MITRAJL. KH. M.TABRANI BLOK I NO. 1 A-1B, MARGAMULIA,
BEKASI UTARA021-70266392/8868129| 021-8868129 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
645 1541 RS. PERMATA BEKASI JL. LEGENDA RAYA, NO. 9, MUSTIKA JAYA 021-8251919/8254748| 021-82609705 Y Y ALL COVERAGE
646 1559 RB & KLINIK TIARA BUNDA JL. RAYA PERJUANGAN NO. 1, PERTIGAAN TELUK PUCUNG 021-89131010| 021-89131010 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
647 1122 RS. JATI SAMPURNA JL. STUDIO ANTV KRANGGAN 021-8451457| 021- 8455712 Y Y ALL COVERAGE
648 1576RS TAMAN HARAPAN BARU (d/h praktek
bersama dokter)
JL KALIABANG TENGAH RT 04/23 KEL. PEJUANG KEC.
MEDAN SATRIA021-88981055| 021-88981055 Y Y ALL COVERAGE
649 0063 RS. MULTAZAM MEDIKA JL. PERUMAHAN JATIMULYA NO.1 TAMBUN SELATAN021-8215101/8215102021-
8215102|021-8215102021-82416678 Y Y ALL COVERAGE
650 1553 RS. HERMINA GRAND WISATAJL. FESTIVAL BOULEVARD BLOK JA NO. I, GRAND
WISATA,021-8265 1212| 021-825 2963 Y Y ALL COVERAGE
651 0016 RS. KARYA MEDIKA CIBITUNGJL. RAYA IMAM BONJOL, NO.9B, CIKARANG BARAT,
CIBITUNG
021-8900190-1& 8903003-4/
8900190-1 (ext:181)|021-89107753-4 Y Y ALL COVERAGE
652 0947 RS. APRILIA MEDIKAJL. RAYA SETU NO.99 DESA LUBANG BUAYA, KEC SETU
BEKASI
021 - 82611565/82603851|021-
5901312021 - 82611565 Y Y ALL COVERAGE
653 0949BP DR. SANDER B(D/H KLINIK HOSANA
MEDICA CIBITUNG)JL. TEUKU UMAR NO.19 CIBITUNG 021-8833 8414-|- 021-8833 8413 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
654 0950KLINIK HOSANA MEDICA MANGUN JAYA
(HOSANA MEDIKA IV
JL. MANGUN JAYA INDAH II BLOK G10 NO. 3 TAMBUN
BEKASI 17510(021) 8832-0349-|- (021) 8832-0349 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
655 2057 KLINIK BATARA SATU MEDIKAJL. KH. NOER ALI NO. 10 KP. IRIAN RT. 03/04 TELUK
PUCUNG, BEKASI UTARA021-89133229/085100589090| 021-82589090 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
656 2091 KLINIK SITI ZAHROH PERUMAHAN GRAND RESIDENT RR 100 SETU - BEKASI 021-8261.8362| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
657 2252 KLINIK DR NOPENPERUM TELAGA MURNI BLOK D1 NO. 10 TELAGA MURNI,
CIKARANG BARAT BEKASI ¿ 17520021- 8910 7022| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
658 1965 KLINIK KU JL. DR. RATNA JATI ASIH BEKASI 021-84901303| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
659 0891 RS. HERMINA GALAXY JL. GARDENIA RAYA SELATAN BLOK BA1 NO.11 021-8222525/82417777| 021-82414087 Y Y ALL COVERAGE
660 2433 KLINIK TAMAN FIRDAUS MEDIKAPERUM TAMAN FIRDAUS RESIDENCE BLOK A 06 NO.17
CIBARUSA BEKASI021 - 89950047| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
661 2611 KLINIK AMELIAVILA MUTIARA GADING 2 KOMPLEK RUKO ROXY BLOK
DD.10 NO.1 KARANG SATRIA BEKASI021-88376985| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
662 1588 RB. ASYIFA HUSADA MEDICAL CENTER PERUM. BEKASI REGENCY I BLOK K I NO. 1, CIBITUNG 021-88332152| 021-88332152 Y Y ALL COVERAGE
663 1595 KLINIK VNV MEDIESTETI KOMPLEK PEMDA BLOK C JATI ASIH BEKASI 021-82435767| 021-82435767 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
664 1334 RS. ANNA MEDIKAJL. RAYA PERJUANGAN NO 45, HARAPAN BARU, BEKASI
UTARA021 - 88882211| 021 - 88973042 Y Y ALL COVERAGE
665 1586 RS. BUNDA MULIA (d/h) RSIA SRITINA JL. IMAM BONJOL NO.80A BEKASI 021-8900579-89106317| 021-89106633 Y Y ALL COVERAGE
666 1640 RS. JATI RAHAYU JL. RAYA HANKAM NO 17 PONDOK MELATI BEKASI 021-8462566,8462565,84972578| 021-84992723 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
667 1769 KLINIK SATELIT GSM BEKASIBEKASI SQUARE NO 65-66 JL. AHMAD YANI PEKAYON
JAYA BEKASI SELATAN021-82425408| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
668 4814 KLINIK MULTAZAMJL. RAYA CIBARUSAH NO. 33KEL. SUKARESMI, KEC.
CIKARANG SELATAN, BEKASI(021) 9874929| - N Y ALL COVERAGE
669 0161 RS. MITRA KELUARGA BEKASI TIMURJL. PENGASINAN RAWA SEMUT MARGAHAYU,
BEKASI TIMUR021-8817777/89999222| 8820707/89999286 Y Y ALL COVERAGE
670 1989 RSIA. KARUNIA KASIH (KARUNIA BUNDA)JL. RAYA JATI WARINGIN NO. 133 PONDOK GEDE KOTA
BEKASI021-8461970| 021- 8460991 Y Y ALL COVERAGE
671 3367 KLINIK CENTRAL MEDIKA2JL. KH. FUDHOLI (KEBON KPI) DESA KARANG ASIH, KEC.
CIKARANG UTARA KAB. BEKASI021-89100879| 021-89100877 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
672 3447 KLINIK RAWAT INAP PEDULI SEHATJL. RAYA PILAR SUKATANI KP. SUKAMANTRI NO 62 RT
03/03 DS SUKARAYA KEC KARANG BAHAGIA021-8903208| 021-89100139 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
673 0178 RS. HERMINA BEKASI JL. KEMAKMURAN, NO.39, MARGAJAYA 021-8842121/30| 021- 88952275 Y Y ALL COVERAGE
674 2560 MITRASANA MOCHTAR TABRANIJL. KH MUCHTAR TABRANI RT 003 RW 03 KEL. PERWIRA
KEC. BEKASI UTARA KOTA BEKASI36822504/ 08891259008| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
675 2515 MITRASANA KALIABANG"RUKO FITRA JAYA, JL. KALIABANG RT 01/06 NO. 7 KEL
PERWIRA KEC BEKASI UTARA021-88974206| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
676 2518 MITRASANA MUTIARA GADING TIMUR
RUKO MUTIARA GADING TIMUR 2 BLOK R 02-23
KELURAHAN MUSTIKA JAYA KECAMATAN BANTAR GEBANG
BEKASI
085100771573| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
677 2520 MITRASANA UJUNG HARAPAN"KAMPUNG UJUNG HARAPAN RT 02/ RW 15 KEL. BAHAGIA
KEC. BABELAN KAB. BEKASI021-29258727/ 70874627| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
678 2521 MITRASANA BUMI SANI PERMAI"JL. BUMI SANI PERMAI RT 02 RW 011 KAMPUNG BULU
KEL SETUIA MEKAR KEC TAMBUN SELATAN BEKASI71347468| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
679 2523 MITRASANA HARAPAN BARU 2"PERUM HARAPAN BARU II D8-02 RT 03 RW 02 KOTA BARU
BEKASI BARAT88950943| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
680 2525 MITRASANA SAKURA REGENCY"JL. WIBAWA MUKTI 2 KOMP. SAKURA REGENCY BLOK KM
8 ¿ 12 JATIASIH BEKASI021-82441692| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
681 2527 MITRASANA KOTA SERANG BARU"JL. PERUM KOTA SERANG BARU BLOK A/47 NO 5 KEL
SUKARAGAM, KEC SERANG BARU KAB BEKASI36502354| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
682 2535 MITRASANA PEJUANG HARAPAN BARUJL. PEJUANG 04 BLOK B/ 234 RT 13 RW 11 PEJUANG
MEDAN SATRIA021-70813640| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
683 2539 MITRASANA PONDOK TIMURPONDOK TIMUR INDAH BLOK G NO 1 PONDOK TIMURKEL
JATIMULYA KEC TAMBUN SELATAN KAB BEKASI085100822510| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
684 2545 MITRASANA TITIAN INDAHJL. PERUM TITIAN INDAH BLOK I NO 9 RT 07 RW 10 KEL.
KALIBARU KEC MEDAN SATRIA KOTA BEKASI021-94178815| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
685 2528 MITRASANA ALAMANDA REGENCY"JL. KAMPUNG RAWA KALONG RT 01/ RW 03 KARANG
SATRIA BLOK N 01 NO 43 TAMBUN UTARA, BEKASI70874627/ 08891258883| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
686 2534 MITRASANA KRANJIJL. FAJAR NIAGA D1 NO 73 KEL JAKA SAMPURNA KEC
BEKASI BARAT88951275| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
687 2613 KLINIK & APOTIK MAHADINA MEDIKA JL. KH. BOSIH NO.9 CIBITUNG -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
688 2802 KLINIK PERTAMEDIKA BEKASIRUKO KALIMALANG SQUARE BLOK J NO. 17, JL.
KALIMALANG RAYA - BEKASI BARAT021-88962946| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
689 2803 KLINIK PERTAMEDIKA JATIWARINGIN ASRI JL. SANGATTA NO. 1 JATIWARINGIN PONDOK GEDE 17411 021-84990644| 021-84970944 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
690 2689 KLINIK & APOTEK KF 367 JL. JATIMEKAR NO. 33 JATIASIH 021 8473403| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
691 4815 RS. PERMATA KELUARGA (JABABEKA)JL. DR. CIPTO MANGUNKUSUMO BLOK A NO. 1A, DESA
SIMPANGAN, KEC. CIKARANG UTARA, BEKASI 17550( 021 ) 29083399| (021) 8990 1860 Y Y ALL COVERAGE
692 1558 KLINIK ASYIFA HUSADAPERUM. VILLA MUTIARA JAYA BLOK N. 78 /11-12,
WANAJAYA, CIBITUNG021-88338235| 021-88338235 N Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
693 0735 RS. KARTIKA HUSADA TAMBUNJL. MANGUN JAYA RAYA KP.RUKEM RT.003/013, DESA
MANGUN JAYA, TAMBUN - BEKASI
021-88338346/88327281/021-
9172736|021-9172736021-88322529 Y Y ALL COVERAGE
694 4693 RS. CIKUNIR JL. RAYA CIKUNIR GG. HJ NAPSIAH RT.06/03 , JAKAMULYA (021) 82437322| (021) 82437323 Y Y ALL COVERAGE
Page 15 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
695 4743 KLINIK TRAYAJL. KH. NOER ALI NO. 1D RT. 001 RW.016, JAKA
SAMPURNA, BEKASI BARAT BEKASI 17137(021) 21286002| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
696 4811 RSU. AS-SHOFWANJL. RAYA KARAWANG BEKASI KM 30 DS. BOJONGSARI
KEDUNGWARINGIN KAB. BEKASI(021) 89141890| (021) 89141754 Y Y ALL COVERAGE
697 1204 KLINIK SEHAT SEJAHTERA II PERUM REGENSI - BEKASI TIMUR 021-88367194| 88349427 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
698 1971 RB. WIJAYANTIJL. PERUM GRIYA BEKASI PERMAI BLOK H6 NO 17,
TELAJUNG-CIKARANG BARAT021-29371856/97958619| 021-82602243 Y Y ALL COVERAGE
699 4378 KLINIK MATA NUSANTARA (BEKASI)RUKO SENTRA NIAGA KALIMALANG, JL. A.YANI BLOK A9
NO. 16, KEL. MARGA JAYA, KEC. BEKASI SELATAN(021) 2925 7761| (021) 2925 7762 N Y GP,OP
700 0147RS KARYA MEDIKA BANTAR GEBANG(d/h
KARYA MEDIKA IV)JL. NAROGONG RAYA, KM.11, BANTAR GEBANG 021-8254629/8254630|021-8254630 021-8254629 Y Y ALL COVERAGE
701 4515 PRODIA SUMMARECON BEKASIJL. BULEVAR SELATAN SUMMARECON BEKASI RUKO
SINPASA BLOK SA021-8840480| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
702 1350 RS. MITRA KELUARGA CIBUBUR JL. ALTERNATIF TRANSYOGI, CIBUBUR 021-84311771/84311777| 021-84311661 Y Y ALL COVERAGE
703 3382 KHARISMA MEDICAL CENTER JL. CAMAN RAYA NO.54 BEKASI 021-84991671| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
704 4726 KLINIK CAHAYA AMALIAJL. KH. MUHTAR THABRANI NO. 3-5 KEL. PERWIRA, KEC.
BEKASI UTARA, BEKASI(021) 88879888| (021) 88881747 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
705 5220 VIVA MEDIKA BEKASI TIMURJL. CUT MUTIA BLOK D NO. 9 RT. 008/ 008 KEL.
MARGAHAYU, KEC. BEKASI TIMUR, BEKASI(021) 8834 8228| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
706 5221 KLINIK SILOAM BLU PLAZAJL. CHAIRIL ANWAR BLU PLAZA NO. 27 RT.004/009 KEL.
MARGAHAYU KEC. BEKASI TIMUR, BEKASI(021) 806 11 900| (021) 806 11 911 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
707 5222 VIVA MEDIKA TAMBUNRUKO TAMBUN CITY BLOK RB NO. 16, JL. SULTAN
HASANUDDIN KEC. TAMBUN SELATAN088888553853| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
708 5223 VIVA MEDIKA CIKARANG
RUKO CIKARANG CENTRAL CITY BLOK F NO. 23, JL.
CIKARANG CIBARUSAH DESA CIANTRA KEC. CIKARANG
SELATAN, BEKASI
(021) 2961 9212| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
709 4385 KLINIK & APOTEK KF 340 JL.KEDASIH RAYA NO.112 CIKARANG -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
710 3702 PRODIA HARAPAN INDAHRUKO SENTRA NIAGA, BOULEVARD HIJAU BLOK C5/41
HARAPAN INDAH, BEKASI(021) 29465476| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
711 2512 MITRASANA KAMPUNG CEREWED
RUKO LIBERS. A GARDEN NO. 23 JL. KARANG
SATRIA(SEBELAH PERUM KAMPUNG CEREWED), DUREN
JAYA BEKASI TIMUR
88343753| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
712 2036 RSIA DR IQBALI TAUFANVILA MUTIARA CIKARANG 2 BLOK E3 No 16-20
SUKASEJATI, CIKARANG SELATAN - BEKASI021-89902361;8971769| 021-89902361 Y Y ALL COVERAGE
713 1123 RS. CITRA HARAPANJL. RAYA HARAPAN INDAH KAW.SENTRA NIAGA NO.3-5
MEDAN SATRIA
021-88870606/88870909/88865792-
93|021-88975555 Y Y ALL COVERAGE
714 3956 APOTEK KIMIA FARMA CAHAYA AMALIAJL. KH.MUCHTAR TABRANI NO.3-4, KEL.PERWIRA BEKASI
UTARA02188879888| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
715 4484 KLINIK & RB KARUNIA MEDIKA CENTERJL. GATOT SUBROTO NO. 37 RT.003/002 KEL. CIKARANG -
BEKASI021-89104266| - N Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
716 5422 KLINIK MUSTIKA HUSADAJL. RAYA BURANGKENG PERUM MUSTIKA GRANDE BLOK J
NO. 5 DESA BURANGKENG KEC. SETU, BEKASI(021) 88326109/087880880370| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
717 0151 KLINIK MULYA MEDIKA (APOTIK MURNI) JL. RAYA JATI MULYA, NO.1, BEKASI TIMUR 021-8203272| 021-8203272 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
718 0847 RS. ANNA JL. PEKAYON RAYA NO.36, BEKASI SELATAN 021-82432211| 021-82419079 Y Y ALL COVERAGE
719 1261 RS. HOSANA MEDICA BEKASI JL. PRAMUKA NO.12 RAWA LUMBU 021-8221570/73| 021-8224604/8221574 Y Y ALL COVERAGE
720 1062 RS. CIBITUNG MEDIKA JL. RAYA H.BOSIH NO.117 DS.WANASARI,CIBITUNG 021-88323444/88393181-|- 02188323449/88372866 Y Y ALL COVERAGE
721 1333 RSU. KARTIKA HUSADA JATIASIH JL. SWANTARA NO 72 JATI ASIH, BEKASI 021-82435585-82435587| 021-82435586 Y Y ALL COVERAGE
722 1951 KLINIK & APOTEK KF 387 JL. JATIWARINGIN NO 5 PONDOK GEDE BEKASI 021-8461980| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
723 2594 MITRASANA BUMI CIKARANG MAKMURBUMI CIKARANG MAKMUR BLOK F 10 NO. 6 KEL.
SUKADAMI, KEC. CIKARANG SELATAN, KAB. BEKASI021-36164232/ 021-34618046| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
724 2508 MITRASANA TAMAN HARAPAN BARUJL. TAMAN HARAPAN BARU BLOK E7 NO 9, PEJUANG,
MEDAN SATRIA, BEKASI BARAT88870793 / 08891259038| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
725 2531 MITRASANA GRAND WISATA
RUKO CELEBRATION BOULEVARD BLOK AA9 NO.12
PERUMAHAN GRAND WISATA KEL. LAMBANG SARI KEC.
TAMBUN BEKASI
71209133 / 08891258904| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
726 2461KLINIK 24 JAM & RB. PERMATA BUNDA
CIBITUNGJL. RAYA WANAJAYA - CIBITUNG, BEKASI 021 - 88322064, 88323062| - Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
727 5614 KLINIK MATA UTAMA JEC CIBUBURJL. ALTERNATIF CIBUBUR -CILUENGSI RT.001/011, KEL.
JATIKARYA KEC. JATISAMPURNA, BEKASI(021) 29221000| -
N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
728 2511 MITRASANA DUKUH ZAMRUDJL. ZAMRUD UTARA RUKO BLOK S.1 NO. 18 KOTA
LEGENDA,BEKASI TIMUR08891258897/ 82602911| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
729 2513 MITRASANA MEGA REGENCY 2"JL. PERUM MEGA REGENCY BLOK D3 NO 5 KEL
SUKARAGAM KEC SERANG BARU KAB BEKASI36771573/ 08891259006| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
730 0843 KLINIK DHARMA BHAKTIJL. RAYA BOSIH BLOK A4 NO.23 PONDOK TANAH MAS,
CIBITUNG - BEKASI021-8831441-|- 021-8831441/8830246 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
731 2821 LAB. PRODIA BEKASIJL. KH NOER ALI NO.90 RT.01 RW.25 KAYURINGIN JAYA,
BEKASI SELATAN.(021) 8840480, 8844911| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BOGOR
732 2955 RS. PERMATA JONGGOLJL. RAYA JONGGOL NO.1 A RT.008 RW.03, SUKAMANAH,
JONGGOL, BOGOR021-8993 1222 - 1444| 021- 8993 1836 Y Y ALL COVERAGE
733 4983 KLINIK GRACIAJL. RAYA NAROGONG KM. 17 (PANGKALAN 9) DESA
CILEUNGSI, KEC. CILEUNGSI(021) 82486305| (021) 82486305 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
734 3990 RSIA. BUNDA SURYATNIJL. KH. SOLEH ISKANDAR NO. 21, CIBADAK, TANAH
SAREAL, BOGOR 16161(0251) 754 3892/7543891| (0251) 754 3893 Y Y ALL COVERAGE
735 2172 KLINIK BHAKTI RAHAYU LEUWILIANG JL. RAYA GALUGA NO. 120 CIBUNGBULANG, BOGOR 0251-8648201| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
736 0411 RS. AZRA JL. RAYA PAJAJARAN, NO.219 0251-8318456-|- 0251-8331773/8324093 Y Y ALL COVERAGE
737 1833 KLINIK PELITA SEHAT TAMAN KENARIRUKO PERUMAHAN TAMAN KENARI BLOK E3 NO 4, TANAH
BARU BOGOR0251-8664767| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
738 1831 KLINIK PELITA SEHAT CIBINONGCENTRAL RUKO CIBINONG BLOK B No 1-2 JL. MAYOR
OKING No 63021-87910241/08998513939| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
739 2718 KLINIK PELITA SEHAT CIOMASJL. RAYA TAMAN PAGELARAN BLOK C1 NO.5, PADASUKA,
CIOMAS, BOGOR(0251) 7522167| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
740 2624 IZI CLINIC JL. ACHMAD ADNAWIJAYA NO.115 (0251) 8359111| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
741 1662 RSIA. KENARI GRAHA MEDIKA GRIYA KENARI MAS BLOK B2 CILEUNGSI 021-8230426/82499885/96684076| 021-8231829 Y Y ALL COVERAGE
742 2191 RS. MEDIKA DRAMAGA JL. RAYA DRAMAGA KM. 7.3 MARGAJAYA BOGOR 0251- 8308900; 081319310610| 0251- 862577 Y Y ALL COVERAGE
743 3000 RSUD. KOTA BOGOR JL. DR. SUMERU NO. 120 MENTENG, BOGOR BARAT 16111 0251-8312292| 0251-8371001 Y Y ALL COVERAGE
744 2824 LAB. PRODIA BOGOR JL. JEND. SUDIRMAN NO.38 B, BOGOR 16143 (0251) 8351612, 8351614| 0251-8351614 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 16 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
745 0673 RSU. MELANIA JL. RAYA PAHLAWAN NO.91 BONDONGAN - BOGOR0251- 8321196021-4506389|021-
45063890251-8331777 Y Y ALL COVERAGE
746 0190 RS. ISLAM BOGOR JL. PERDANA RAYA NO.22, BUDI AGUNG - KEDUNG BADAK 0251 - 8316822, 834713| 0251 -8347139 Y Y ALL COVERAGE
747 0835 RS. FAMILY MEDICAL CENTRE BOGOR JL. RAYA BOGOR KM.51 CIMANDALA-SUKARAJA (0251) 8652391| 0251-8661 605 Y Y ALL COVERAGE
748 0932 KLINIK MHT CIPAYUNG JL. RAYA PUNCAK CIPAYUNG, KM 75 0251-8256172-|- 0251-8257648 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
749 1103 RS. TRIMITRA CIBINONG JL. RAYA CIBINONG KM.43021-8763055-56021-8765993|021-
8765993021-8758038 Y Y ALL COVERAGE
750 1251 KLINIK INSANI CIBINONG JL. MAYOR OKING, NO.58A, CIRIUNG, CIBINONG 021-8757567| 021-8757567 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
751 0290 RS. MARY CILEUNGSI HIJAU JL. RAYA NAROGONG, KM.21, CILEUNGSI 021-82492222| 021-82493902 Y Y ALL COVERAGE
752 0706 POLIKLINIK CIBULUH JL. KEDUNG HALANG TALANG, NO.148 0251-8661947| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
753 1673 RB. PELITA SEHAT POMADJL. RAYA CIBULUH RUKO NO 9 SIMPANG POMAD KEC
BOGOR UTARA0251-8658811| 0251-8652628; Y Y ALL COVERAGE
754 0468 RS. PMI BOGOR JL. RAYA PAJAJARAN, NO.80 0251-8324080-|- 0251-8382936/8324709 Y Y ALL COVERAGE
755 1832 KLINIK PELITA SEHAT BANGBARUNG JL. ACHMAD SOBANA/ BANGBARUNG 77 BOGOR 0251-8362525 / 089637057022| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
756 1823 KLINIK SALSABILA MEDICAL CENTREJL. KSR DADI KUSMAYADI RUKO LAMPU MERAH CIKARET
NO. 70 CIBINONG-BOGOR021-87905768| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
757 1913 KLINIK PURI MEDIKAJL. RAYA CIKARET NO. 12 RT.03 RW.10 KAMPUNG POS
PAKANSARI CIBINONG, BOGOR021-87903120| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
758 1419RB & KLINIK CITAMA KEDUNG WARINGIN
GAVERIJL. BOJONG GEDE-BOGOR 021-87983434| Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
759 1525 EMMA MEDICAL CENTER 2 JL. RAYA CICADAS, KM.9, NO.21, GUNUNG PUTRI 021-86860577/91304486| 021-86860578 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
760 1297 RB & KLINIK INSANI JL. PAHLAWAN NO.73B CITEUREUP 021.70247742/ 87942723| 021-87942570 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
761 1353 RS. CITAMA JL. RAYA PABUARAN NO. 52 BOJONGGEDE-BOGOR 021-87985555| 021-87986666 Y Y ALL COVERAGE
762 1533 KLINIK DR.BETTYJL. RAYA NAROGONG, PERUMAHAN PT.SEMEN CIBINONG,
CILEUNGSI021-82493032| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
763 0133 RS. HERMINA BOGOR JL. RING ROAD-1, KAV.23,25,27, PERUM. TMN. YASMIN 0251-8382525| 0251-8328252 Y Y ALL COVERAGE
764 0755 RS. BINA HUSADA CIBINONG JL. MAYOR O KING NO.101, CIBINONG - BOGOR021-8758441; 87911000021-
8753422-|021- 8753422-021-8752463 Y Y ALL COVERAGE
765 0992 RS. BOGOR MEDICAL CENTER JL. PAJAJARAN INDAH V/97 BOGOR
0251-
8307900/8390435/8346002/8379743
0251-346002|0251-346002
0251-8313987/8353419 Y Y ALL COVERAGE
766 2116 RS. HERMINA MEKARSARIJL. RAYA CILEUNGSI - JONGGOL KM 1 KABUPATEN BOGOR
16820021-29232525| 021-2923770 Y Y ALL COVERAGE
767 0720 RSIA. CITRA INSANIJL. RAYA PARUNG NO.242, LEBAKWANGI PEMAGARSARI,
PARUNG
0251 - 8611507/86177270251-
611507|0251-6115070251 - 8617493 Y Y ALL COVERAGE
768 1952 KLINIK & APOTEK KF 50 JL. MERDEKA NO 24 BOGOR 0251-8384247 / 8321525| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
769 1385 RS. SENTRA MEDIKA CIBINONG JL. MAYOR OKING JAYA ATMAJA NO.9 CIBINONG 021-87909999/87911212| 021-87909377 Y Y ALL COVERAGE
770 2441 KLINIK NADYA MH THAMRINJL. KH ABDULLAH BIN NUH RT. 005/ RW. 01 KEL.
SINDANG BARNAG, KEC. BOGOR BARAT(0251) 8624629| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
771 2388 RS. PERTAMEDIKA SENTUL CITY JL. MH THAMRIN KAV 57 SENTUL CITY - BOGOR 16810 021-29672990/29672977| - Y Y ALL COVERAGE
772 2456 RSIA. JULIANA JL. RAYA TAJUR NO 75A - BOGOR 0251 - 8339593| 0251-8339591 Y Y ALL COVERAGE
773 1679 RS. ANNISA CITEUREUP JL. KARANGGAN NO 02 PUSPASARI CITEUREUP - BOGOR 021-8756780; 8752628| 021-8752628 Y Y ALL COVERAGE
774 1680 RSIA. SENTOSA JL. RAYA KEMANG NO 18 BOGOR 0251-7541900| 0251-7541900 Y Y ALL COVERAGE
775 2809 KLINIK PERTAMEDIKA BOGORJL. PANDAWA BLOK A-1 NO 14-15 BANTAR JATI II BUMI
INDAH PRASTA I0251-8363994| 0251-8363993 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
776 3709 RS. VANIA JL. SILIWANGI NO.11 SUKASARI BOGOR TIMUR 0251-8380601/8380605| 0251-8380612 Y Y ALL COVERAGE
777 2979 LAB. KLINIK KIMIA FARMA BOGOR JL. IR. H. JUANDA NO. 30, BOGOR 0251 - 8319030| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
778 2772 KLINIK SHIFA MEDIKAJL. BRANTA MULIA RT.002/07 KARANG ASEM TIMUR,
CITEUREUP - BOGOR(021) 8760357| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
779 2759 RS. KARYA BHAKTI PRATIWI JL. RAYA DRAMAGA KM. 7, DRAMAGA, BOGOR (0251) 8626868| (0251) 8626969 Y Y ALL COVERAGE
780 2788 RSIA. ASSALAMJL. RAYA BOGOR KM 46, NANGGEWER MEKAR, CIBINONG,
BOGOR(021) 8753724| - Y Y ALL COVERAGE
781 2703 KIMIA FARMA 362 JL. MAYOR OKING 112 C, CIBINONG 021 87914400| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
782 2393 RS. UMMI JL. EMPANG II NO.2 BOGOR RT.004/002 BOGOR SELATAN 0251-8341600| 0251-8341606 Y Y ALL COVERAGE
783 3420 RS. MULIA PAJAJARAN JL. RAYA PAJAJARAN NO. 98, BOGOR 0251-8379898| 0251-8378800 Y Y ALL COVERAGE
784 4694 RSB. PASUTRI JL. MERAK NO. 3 TANAH SAREAL, BOGOR (0251) 8349707| (0251) 8331938 Y Y ALL COVERAGE
785 0389 RS. MH THAMRIN CILEUNGSIJL. RAYA NAROGONG, KM.16, LIMUS NUNGGAL,
CILEUNGSI
021-8235052 / 82491332021-
82491332|021-82491332021-82491331 Y Y ALL COVERAGE
786 1235 KLINIK & APOTEK KF 7 BOGOR JL. IR. H JUANDA NO. 30 0251-8363473 / 8319030 (Lab)| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
787 2753 KLINIK ARABBANIJL. RAYA KARET VILLA TELAGA CIBINONG NO.07-08,
HARAPAN JAYA CIBINONG, BOGOR(021) 87910118;| (021) 87910118 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
788 2517 MITRASANA VILLA NUSA INDAHPERUM VILLA NUSA INDAH BLOK F2 NO. 15 DESA BOJONG
KULUR KEC. GUNUNG PUTRI KAB. BOGOR82429508| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
CIAMIS
789 4125 LAB. PRODIA CIAMIS JL. JEND. SUDIRMAN NO. 99, CIAMIS 0265-2750977| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
790 1104 RS. PERMATA BUNDA CIAMIS JL. MR.IWA KUSUMASOMANTRI NO.10265-771650/7767450711-
356173|0711-3561730265-777658 Y Y ALL COVERAGE
CIANJUR
791 2121 KLINIK ASSALAM CIKALONG JL. RAYA CIKALONG KULON NO. 61 A KAB. CIANJUR 0263-318222| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
792 4107 RS. DR.HAFIZJL. PRAMUKA NO. 15 SUKAMULYA, KARANG TENGAH,
CIANJUR0263-2910000| (0263) 2910010 Y Y ALL COVERAGE
793 2123 KLINIK PADJADJARAN SUKANAGARA JL. RAYA SUKANEGARA KM.45 SUKANEGARA - CIANJUR 0263-340189/ 085794056664| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 17 of 40
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
CIKAMPEK
794 2472 RB & KLINIK NAURAH MEDIKAJL. A. YANI NO.02 RT.03 RW. 06 DS. CIKAMPEK SELATAN,
CIKAMPEK(0264) 8389999| - Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
795 1749 APOTEK NAGASARI JL. JEND A. YANI NO 177 CIKAMPEK 0264-316203| 0264-316203 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
796 2445 RS. TITIAN BUNDA JL. IR. H. JUANDA NO.123 CIKAMPEK (0264) 8385999/8386222| (0264) 8388936 Y Y ALL COVERAGE
797 1497 KLINIK SEHAT JL. PAWARENGAN NO. 37, DESA DAWUAN TIMUR 0264-8385103| 0264-8385103 N YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
798 1302 KLINIK PURI ASIH CIKAMPEK JL. STASIUN NO.2 CIKAMPEK KOTA 0264-303558| 0264-303558 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
799 1300 KLINIK ANDINA CIKAMPEK JL. IR.H.JUANDA NO.17 0264-303759| 0264-8387680 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
800 0908 KLINIK KELUARGA GRAHA MEDIS JL. ACHMAD YANI NO. 51 0264-310101| 0264-310101 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
801 1409 RSU. PURI ASIH JATISARI JL. RAYA JATISARI NO.3 PASAR JATISARI 0264-361459/361466| 0264-8375276 Y Y ALL COVERAGE
802 1172KLINIK PUTRA MEDIKA ( GROUP AQMA
PUSAT )JL. IR. H. JUANDA NO.14-19 SUKASEURI 0264-301652 / 8387129| 0264-8387129 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
803 0375 RS. KARYA HUSADA JL. JEND. A.YANI, NO.98, CIKAMPEK-KARAWANG 0264-316188-89| 0264-312834/301626 Y Y ALL COVERAGE
804 0540 RS. SARASWATIJL. JEND. A.YANI, NO.92, DAWUAN, CIKAMPEK-
KARAWANG
0264-311531/316101/ 311514/
3115270264-316391|0264-3163910264-311531 Y Y ALL COVERAGE
805 0093 KLINIK AQMA CIKAMPEK JL. STASIUN, NO.93 0264 - 310 524| 0264 - 319307 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
806 1239RUMAH SAKIT IZZA D/H (RSU. AQMA
CIKAMPEK)JL. KP.CISELAN DS.CIKAMPEK UTARA.KARAWANG 0264-319307/8386830-32| 0264-8386829 Y Y ALL COVERAGE
CIKARANG
807 0391 SILOAM HOSPITALS LIPPO CIKARANG JL. MH. THAMRIN, KAV.105, LIPPO CIKARANG 021- 29636900| 021-89900022/8972470 Y Y ALL COVERAGE
808 2505 MITRASANA MEGA REGENCYRUKO KOTA MEGA REGENCY BLOK A 01 NO. 10, JL. RAYA
CIKARANG - CIBARUSAH KM 1070326665| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
809 0916 RB & KLINIK GRAHA BINA HUSADAJL. INDUSTRI SELATAN NO.1A, BLOK NN 3A, INDUSTRI
JABABEKA II021-89836243-|- 021-89836244 Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
810 2464 MITRASANA PTRUKO PLAZA ROXY BLOK C NO. 8 JL. KASUARI RAYA,
KOTA HIJAU JABABEKA, CIKARANG BARU021-89835394| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
811 4032 RB & KLINIK RIA PILAR JL. GATOT SUBROTO NO. 67 CIKARANG(021) 89105057 / 98284832;
085669228852|(021) 8900487 Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
812 3992 KLINIK CENTRAL MEDIKA 3JL. RAYA RENGAS BANDUNG NO.20 001/003,KARANG
SAMBUNG,KEDUNG WARINGIN,BEKASI021-89142220| 021-89142221 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
813 1308 RS. RIDHOKA SALMA JL. IMAM BONJOL NO.7 GARDU SAWAH 021-89116527| 021-89116528 Y Y ALL COVERAGE
814 0275 RS. SENTRA MEDIKA CIKARANGJL. RAYA INDUSTRI PASIR GOMBONG JABABEKA,
CIKARANG
021 8904160-64 / EXT
225/081297102702|021-8904159,89111112 Y Y ALL COVERAGE
815 4759 KLINIK PUTRA MEDIKA 2JL. RAYA CIKARANG CIBARUSAH KM. 28 RT. 012/006 DESA
CIANTRA KEC. CIKARANG SELATAN(021)8971612| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
816 2742 KLINIK SUMBER SEHATJL. KH FUDOLI NO 50 RT.001/004 DS KARANG ASIH KEC.
CIKARANG UTARA 17530(021) 8900566 / 89106020| (021) 8900566 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
817 1287 RB & KLINIK NIZA ASYIFA BERSAMA 1PERUMAHAN TELAGA HARAPAN BLOK E1 NO.1 CIKARANG
BARAT021-89109638| 021-89109638 Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
818 1034 KLINIK HARAPAN SEHAT IIRUKO TELAGA HARAPAN BLOK F NO.16, PERUMAHAN
TELAGA HARAPAN, CIKARANG BARAT021-8904519-|- - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
819 1041RS HARAPAN KELUARGA (d/h RS.HARAPAN
INTERNASIONAL)
JL.KASUARI RAYA KAV.1A-1B, KOTA JABABEKA, CIKARANG
BARU021-89840745|- 021-89835839 Y Y ALL COVERAGE
820 1050 RS. AMANDA CIKARANG UTARA JL. RAYA INDUSTRI NO.36,CIKARANG UTARA021- 8900277 / 89110011021-
8900277|021-8900277021-89110011 Y Y ALL COVERAGE
821 0913 RS. ASRI MEDIKA JL. CITANDUY RAYA BLOK L II NO.1 CIKARANG UTARA 021-89142968, 89142969-|- 02189143860/89143036 Y Y ALL COVERAGE
822 0929 KLINIK RENNICHA PUTRA JL. RAYA CIKARANG CIBARUSAH NO 89 LIPPO CIKARANG021-8971852021-8971658|021-
8971658021-8971852 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
823 0960 RSB. MEKAR MULIAJL. KASUARI IV, SEKTOR MEKAR ALAM,PASIMAL -
CIKARANG BARU021-8936940/66-|- 021-89830523 Y Y ALL COVERAGE
824 0966 RB & KLINIK CENTRAL MEDIKAJL. PILAR - SUKATANI, DS SUKARAYA NO 84, KARANG
BAHAGIA021- 89111103-|- 021-89119714 N Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
825 0967 CITRA ARDHITA MEDIFARMA CAPITOL BUSINESS PARK, BLOK B2, JL. NIAGA RAYA021-89831945/7004236021-
89831946|021-8983194602189831946/89833385 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
826 1119 KLINIK SAPTA MITRA CIKARANGRUKO CIKARANG CENTRAL CITY, BLOK H 29-30
KEL.CIANTRA KEC.CIKARANG SELATAN KAB.BEKASI021-8975369| 021-8975369 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
827 1218 KLINIK CIKARANG MEDIKA JAYA JL. YOS SUDARSO NO.27 CIKARANG 021-8900129; 8901318| 021-8901318 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
828 1415 RB & KLINIK PERMATA BUNDA FUDHOLI JL. KH.FUDHOLY NO 11 KARANG ASIH, CIKARANG UTARA 021-89106080| - Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
829 0263 RB & KLINIK YAYASAN BINA MEDIKA KP. KONGSI, CIKARANG021-8900050; 021-8900051|021-
8900051021-8900051 Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
830 0406 KLINIK ANNISA II (CIKARANG) JL. CIBARUSAH RUKO POIN, NO.31 R 021-8976189| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
831 0738 RS. AMANDA CIKARANG SELATAN JL. RAYA SERANG NO.83 CIKARANG SELATAN021-8971643021-89110011|021-
89110011021-8970808 Y Y ALL COVERAGE
832 0660RS. PERMATA KELUARGA LIPPO CIKARANG
d/h RS HarapanJL. MH.THAMRIN,KAV.129, LIPPO CIKARANG 021-8990 5588/ 8990 1927| 02189901860/89901902 Y Y ALL COVERAGE
833 1795 RB. KHANZA MEDIKAPERUM KOTA SERANG BARU BLOK B 72 NO 25-26,
CIKARANG021-89953361/081212565880| 021-89953117 Y Y ALL COVERAGE
834 1842 RS. MEDIROSSA 2JL. RAYA CIBARUSAH DESA SINDANGMULYA KEC.
CIBARUSAH BEKASI021-89955555| 021-89952355 Y Y ALL COVERAGE
835 1824 KLINIK BUNDA AULIAJL. HAJI RATIM NO. 143 DS JATIWANGI CIKARANG BARAT
- BEKASI021-8998 3742 / 2897 3209| 021-8998 3742 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
836 2061 RS. BUDI ASIH CIKARANGJL. RAYA SERANG - CIBARUSAH RT 01/ RW 01 SERANG
KEC.CIKARANG SELATAN,BEKASI021 - 89677795| 021-89677402 Y Y ALL COVERAGE
837 1234RS. DR. SANDER B (D/H RS. HOSANA
MEDICA PILAR)
JL. K.H.DEWANTARA NO.33,DS KARANG ASIH,CIKARANG
UTARA021-89116176 / 77 / 78| 021-89116179 Y Y ALL COVERAGE
838 1064KLINIK KASIH ANUGERAH SERANG BARU
(HOSANA MEDIKA C
JL. RAYA SERANG-CIBARUSAH KP.BUNISARI RT.07/04
DS.SUKARAGAM SERANG BARU
021-89952605,89952612021-
89952612|021-89952612021-89951205 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
839 1067 RS. MEDIROSSA JL. INDUSTRI TEGAL GEDE - CIKARANG SELATAN 021-89833216| 021-8934979 Y Y ALL COVERAGE
840 1514 KLINIK SUMBER WARASJL. RAYA CIBARUSAH, KAMPUNG CIJAMBE, SUKADAMI,
CIKARANG SELATAN021-8970524| 021-8970524 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
841 1567 RB & KLINIK PUTRA MEDIKAJL. N. PERUM VILA MUTIARA, KAMPUNG KUKUN CIKARANG
NO.115 RT.012/06 DS.CIANTAR021-89677215; 02189677628| 021-89677216 Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
842 1494 RB & KLINIK ANNISA IV JL. RAYA CIBARUSAH NO.63 SERANG BARU 021-89954434| 021-89954434 Y Y ALL COVERAGE
843 1523 RSIA. NURUL ANNISAJL. RAYA CIKARANG CIBARUSA NO 88 DS. SUKARESMI
CIKARANG SELATAN, BEKASI021-897 4854/55| 021 - 8971122 Y Y ALL COVERAGE
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
844 1462 RS. MITRA KELUARGA CIKARANG JL. INDUSTRI RAYA, LEMAH ABANG 021-89840500/89840900| 021-89845489 Y Y ALL COVERAGE
845 0306 RS. ANNISA CIKARANGJL. CIKARANG BARU, NO.31, LEMAHABANG, CIKARANG
UTARA
021-8904165/8901962/8904503021 -
8904503|021 - 8904503021-8903350/89113827 Y Y ALL COVERAGE
846 0385 RS. BHAKTI HUSADA JL. RE. MARTADINATA021-8900530/1021-890 0531|021-
890 0531021-8900570 Y Y ALL COVERAGE
847 0850KLINIK BERKAT MELIMPAH JABABEKA
(HOSANA MEDIKA II)
JL. KAWASAN INDUSTRI I, JABABEKA B8, CIKARANG
UTARA
021-8937941021-8937942|021-
8937942021-8937942,89833055 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
848 2087 KLINIK JB MEDICAL CENTERSHOP HOUSE PERMATA JUNCTION BLOK B A-15 JABABEKA
1 CIKARANG021-89846023/24| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
849 2034 RSIA. CIKARANG MEDIKAJL. KH. FUHDOLI NO.78 KAMPUNG KAUM CIKARANG
UTARA, BEKASI021-8902210| 021-82607637 Y Y ALL COVERAGE
850 1962 KLINIK & APOTEK KEMALAJL. TARUM BARAT 2, RUKO GRAND ARTHA NIAGA 2 BLOK
O2 NO. 23 - 23A021-29083377 - 29083376| 021- N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
851 0574 KLINIK BUDI LUHURJL. RAYA IMAM BONJOL, NO.74, RT.07/04, DESA
SUKADANAU,CIKARANG BARAT021- 88327226/88320116| 021-88327226 Y Y ALL COVERAGE
852 1719 CMC CLINIC ( CIKARANG MEDICAL CENTER )SHOPHOUSE BLOK A NO 14-15, 28-29 JL. JABABEKA RAYA
KAWASAN INDUSTRI CIKARANG021-8934371| 021-8934035 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
853 4670 RS. OMNI CIKARANGOASIS KAV.1 JL. RAYA CIBARUSAH KEL. SUKARESMI, KEC.
CIKARANG SELATAN, BEKASI(021) 2977 9999| 021-2977 9911 Y Y ALL COVERAGE
854 2975 KLINIK PUTRA MEDIKA 3JL. PERUM KOTA SERANG BARU, KP. GEBANG DS.
SUKARAGAM KEC. SERANG BARU, BEKASI(021) 89950333| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
855 2058 RSIA. GIZARJL. VILA MUTIARA CIKARANG, RUKO PASADENA BLOK RA
NO. 3, 5, 6 CIANTRA, CIKARANG SELATAN021-89677240 / 89677204| 021-89677239 Y Y ALL COVERAGE
856 0709 RS. HOSANA MEDICA LIPPO JL. UTAMA BIIE NO 01 LIPPO CIKARANG 021-8972472| 021-89900769 Y Y ALL COVERAGE
857 2454 RS. HOSANA MEDIKA CIKARANG BARUJL. ANGGREK I B2/2 RT.01/11 DS. MEKARMUKTI -
CIKARANG
(021) 89831626; 89835418;
89835223|021-89830442 Y Y ALL COVERAGE
858 2510 MITRASANA TAMAN ASTERRUKO TAMAN ASTER KAV. A3 NO. 41 TELAGA ASIH
CIKARANG BARAT88333364| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
859 2462KLINIK 24 JAM & RB. PERMATA BUNDA
CIKARANG
RUKO GRAMA NIAGA H2 NO. 15/15A, KARANG ASIH -
CIKARANG UTARA021 - 2928 2165, 021 - 2928 2166| - Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
860 2496 KLINIK INSPIRA SABILA MAKMUR RUKO MELAWAI BLOK A NO. 27 TLH LIPPO CIKARAN 085100990164| 2189903336 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
CIMAHI
861 5610 RSAD. TK II DUSTIRA JL DUSTIRA NO. 1 BAROS, KOTA CIMAHI 022-6630932| - Y Y ALL COVERAGE
862 2467 RSU. KASIH BUNDAJL. MAHAR MARTANEGARA NO.166 LEUWIGAJAH - CIMAHI
40521022- 6614221/ 6630585| 022- 6630583 Y Y ALL COVERAGE
863 3610 PRODIA CIMAHI JL. JEND. AMIR MAHMUD NO. 523, CIMAHI 40523 (022) 6658125| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
864 2221 RS. AVISENA CIMAHI JL. MELONGASIH NO. 170 CIJERAH - CIMAHI 022 - 6000830| 022-6000830 Y Y ALL COVERAGE
865 0268 RS. MITRA KASIH JL. RAYA CIBABAT NO.341, CIMAHI 022-6654852,6652774,6654397| 022-6654875/6642349 Y Y ALL COVERAGE
CIREBON
866 0293 RS. PELABUHAN CIREBON JL. SISINGAMANGARAJA, NO.450231-208948/208680 / 0231-
2056570231-205657|0231-2056570231-234670 Y Y ALL COVERAGE
867 2378 RS. KHUSUS JANTUNG HASNA MEDIKAJL. RD GILAP NO. 8 PALIMANAN TIMUR, KABUPATEN
CIREBON0231-343405; 343645| 0231-342224 Y Y ALL COVERAGE
868 1316 RS. MITRA PLUMBON JL. RAYA PLUMBON, KM.11 0231-324483/323100| 0231-322355/322066 Y Y ALL COVERAGE
869 0602 RS. PERTAMINA CIREBON JL. PATRA RAYA, KLAYAN0231-224646; 25121730231-
224646|0231-2246460231-224795; 209328 Y Y ALL COVERAGE
870 4677 RS. PERMATA CIREBON JL. TUPAREV NO. 117 KEDAWUNG, KAB. CIREBON (0231) 883 8877; 833 8899| 0231-8293698 Y Y ALL COVERAGE
871 1091 RS. PUTERA BAHAGIA JL. CIREMAI RAYA NO.114 ,PERUMNAS0231-207351, 4856540231-
485654|0231-4856540231-486356/482328 Y Y ALL COVERAGE
872 2690 KIMIA FARMA 40 JL. PARUJAKAN NO.12 , CIREBON 0231-208954| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
873 1174 RS. SUMBER KASIH JL. SILIWANGI NO.135 0231-203815| 0231-210040 Y Y ALL COVERAGE
874 1029 RS. SUMBER WARAS CIWARINGIN JL. URIP SUMOHARJO, NO.5, CIWARINGIN0231-
342297/341079,3300888,341079-|-0231-342112 Y Y ALL COVERAGE
875 3677 PRODIA CIREBON JL. R.A. KARTINI NO. 32, CIREBON 45122 (0231) 208989| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
876 3882 RSIA. CAHAYA BUNDA JL. RAYA PERJUANGAN NO.8 KESAMBI CIREBON 0231-8333388 / 99| 0231-482121 Y Y ALL COVERAGE
877 2180 APOTEK FARMARIN CIREBON JL. KESAMBI RAYA NO. 92 A 08179416709| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
DEPOK
878 0470 RS. SENTRA MEDIKA DEPOK JL. RAYA BOGOR KM.33 CISALAK - DEPOK 021-874 3790| 0218743230/87741666 Y Y ALL COVERAGE
879 0107 RS. SIMPANGAN DEPOKJL. RAYA BOGOR, KM.36, SIDAMUKTI SUKMAJAYA,
CIMANGGIS - DEPOK021-8741549| 021-8741574 Y Y ALL COVERAGE
880 1007 RS. HARAPAN DEPOK JL. PEMUDA NO.10 021-7520009,7773817,77200005-|- 021-7765883 Y Y ALL COVERAGE
881 2090 KLINIK QITAJL. SEDAP MALAM RAYA NO. 5 KOMP. PERTANIAN DEPOK,
CITAYAM021-87989096| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
882 2078 APOTIK FARMARIN V DEPOKRUKO SALADIN SQUARE C27 JL. MARGONDA RAYA
DEPOK021-29402214| 021-29402214 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
883 1950 KLINIK & APOTEK KF 143 JL. MARGONDA DEPOK 021-7522997| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
884 2219 KLINIK CITRA INSANI JL. RAYA PENGASINAN NO. 5 SAWANGAN DEPOK 0251-8604733/8611507| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
885 1615 RSIA. ASYIFA DEPOKJL. CINERE DEPOK NO 9 RANGKAPAN JAYA BARU
PANCORAN MAS, DEPOK021-77883905/77885454| 021-77885454 Y Y ALL COVERAGE
886 0265 RS. HERMINA DEPOK JL. RAYA SILIWANGI, NO.50, PANCORAN MAS 021-77202525| 021-7763309 Y Y ALL COVERAGE
887 1736 KJP MEDICAL CENTERJL. KEJAYAAN BLOK IX NO 4 KEL SUKMAJAYA DEPOK
TIMUR021-7714605,7703925| 021-7703927 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 19 of 40
MAR-29-2017
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29-Mar-17
888 1776 KLINIK UTAMA RAWAT INAP NAURA MEDIKA JL. KEMAKMURAN RAYA NO 37 DEPOK II 021-77827515| 021-77824756 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
889 1194 RS. HASANAH GRAHA AFIAH JL. RADEN SALEH NO.42 DEPOK 021-77826267/ 77826276| 021-77833796 Y Y ALL COVERAGE
890 1485 RS. MITRA KELUARGA DEPOK JL. MARGONDA RAYA, PANCORAN MAS - DEPOK 021-77210700| 021-77212155 Y Y ALL COVERAGE
891 1056 RS. BUNDA MARGONDA JL. MARGONDA RAYA NO.28 PONDOK CINA-DEPOK 16424 021-78890551-|- 021-78889958 Y Y ALL COVERAGE
892 1318 RB & KLINIK CITAMA CIPAYUNG JL. RAYA CIPAYUNG NO.27 PANCORAN MAS DEPOK 021-87989203/5-021-87982268| 02187986666/8282869 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
893 1085 RS. MEILIA JL. ALTERNATIF CIBUBUR KM.1 CIMANGGIS DEPOK 021-8444444,84598954-|- 021-84598952 Y Y ALL COVERAGE
894 1098 RS. GRHA PERMATA IBU JL. KH. M. USMAN 168,KUKUSAN BEJI 021-7778899-|- 021-7778998 Y Y ALL COVERAGE
895 1266 RB & KLINIK EL RAPHA JL. RAYA BOGOR KM 30 CIMANGGIS - DEPOK 021-8715082/87720327| 021-8715082 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
896 0009 RSU. BHAKTI YUDHA JL. RAYA SAWANGAN-DEPOK 021-7520082| 021-7775862/7762880 Y Y ALL COVERAGE
897 0776 RS. PURI CINERE JL. MARIBAYA BLOK F2, NO.10, PURI CINERE - DEPOK 021-7545488| 021-7545486 Y Y ALL COVERAGE
898 4383 KLINIK TUMBUH KEMBANGJL. ALTERNATIF KM 1 RUKO CIBUBUR POINT BLOK A6-8
HARJAMUKTI, CIMANGGIS DEPOK021-8443316, 8443004| 021-8443018 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
899 2806 KLINIK PERTAMEDIKA CINERE JL. CINERE RAYA NO. 11B 021-7535022| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
900 2808 KLINIK PERTAMEDIKA DEPOK ( MARGONDA) JL. MARGONDA RAYA NO. 270, DEPOK 021-77219363| 021-77219364 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
901 4007 KLINIK UTAMA RAWAT INAP LIMO MEDICARE JL. MERUYUNG RAYA NO. 70, PANCORAN MAS, DEPOK (021) 77888674; 77888675| (021) 77888675 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
902 3329 KLINIK AL-ZAMZAM JL. ABDUL GANI NO. 53, CILODONG, DEPOK (021) 77841431; 87904855| (021) 87904855 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
903 2629 KIMIA FARMA BEJI JL. RAYA NUSANTARA - DEPOK 02177207404| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
904 2627 KLINIK & APOTEK KF 352 JL. MARGONDA RAYA, DEPOK 02178884611| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
905 2628 KLINIK & APOTEK KF 394 JL. SILIWANGI NO.35, DEPOK 02177214567| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
906 2460 KLINIK UTAMA TUGU SAWANGANJL. RAYA MUCHTAR NO. 20 RT.002/007 SAWANGAN -
DEPOK 165110251-8613433/021-29420173| 0251-8613433 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
907 2791 LAB. PRODIA DEPOKRUKO PESONA KHAYANGAN NO.9, JL. MARGONDA RAYA
NO.45, DEPOK 16411(021) 7751178, 7751826| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
908 2760 RS. CITRA MEDIKA DEPOKJL. RAYA KALI MULIA NO. 68 KOTA KEMBANG, CILODONG,
DEPOK021-29671000/5000/7000/8000| 021-29678000 Y Y ALL COVERAGE
909 2722 RS. PERMATA DEPOK JL. RAYA MUCHTAR NO. 22 SAWANGAN DEPOK 021-29669000| 021-29668897 Y Y ALL COVERAGE
910 2630 KLINIK & APOTEK KF 202 JL. KEJAYAAN BLOK IX NO. 2, DEPOK 0217704044| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
911 2825 LAB. PRODIA CIBUBURJL. ALTERNATIF CIBUBUR CILEUNGSI NO. 8 C-D, DEPOK,
JAWA BARAT 16954(021) 84598650, 84590656| (021) 84598651 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
912 4489 KLINIK PERMATA HATIRUKO PERMATA DEPOK BLOK A,5-6 SEKTOR MUTIARA KEL.
PONDOK JAYA, CIPAYUNG, DEPOK(021) 77200935| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
913 0777 RSIA. TUMBUH KEMBANG JL. RAYA BOGOR, KM.31, NO.23, CIMANGGIS021-8701873-74 / 021-8712300|021-
8712300021-8701872 Y Y ALL COVERAGE
914 0346 RS. TUGU IBU JL. RAYA BOGOR, KM.29, CIMANGGIS - DEPOK021-8710870/021-8718634/33|021-
8718634/33021-8708266 Y Y ALL COVERAGE
GARUT
915 2120 KLINIK PADJAJARAN LELES JL. RAYA LELES KEC.LELES KAB GARUT 0262-2458083| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
916 4039 RS. NURHAYATI JL. SUDIRMAN NO. 6 GARUT 0262-238966| 0262-231824 Y Y ALL COVERAGE
917 2994 LAB. KIMIA FARMA GARUT JL. CIMANUK 11A PAMINGGIR (0262) 540077| (0262) 540077 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
918 2934 LAB. PRODIA GARUT JL. RAYA SAMARANG NO. 104, TAROGONG GARUT 0262-2246204| (0262) 2245204 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
919 2699 KLINIK & APOTEK KF 377 JL. CIMANUK NO. 11A, GARUT 0262 233237| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
920 1627 BETHESDA MEDICAL CENTER GARUT JL. CIWALEN NO 43 GARUT 0262-242663,238735| 0262-242663 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
INDRAMAYU
921 4126 LAB. PRODIA INDRAMAYUJL. RAYA PAKANDANGAN ( DEPAN GRIYA ASRI I )
BUNDERAN MANGGA0234-275065| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KARAWANG
922 0689 KLINIK MITRA SEHAT JL. KOSAMBI CURUG, NO.28, KLARI 0267-433930/8402061| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
923 0704 KLINIK CITO KARAWANG JL. KERTABUMI, NO.29 0267-410173/415957| 0267-415957 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
924 0899 KLINIK AULIA KARAWANG JL. PURWASARI KM 6, PURWASARI - KARAWANG 0264-8286755 0811 1889279-|- 0264-8286756 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
925 0197 KLINIK GEMPOL JL. RANGGAGEDE, NO.25 KARAWANG BARAT 0267-412117/8453903| 0267-412117 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
926 0869 RS. DELIMA ASIH SISMA MEDIKA JL. WIRASABA NO.54 JOHAR - KARAWANG 0267-403073/8454248|- 0267-405598 Y Y ALL COVERAGE
927 1022 RSU. FIKRI MEDIKA JL. RAYA KOSAMBI- TELAGASARI, DS BLENDUNG , KLARI0267-8615555/8615566
(KLINIK):0267-433636/435527-|-0267-8615577/88 Y Y ALL COVERAGE
928 1023 RS. ISLAM KARAWANG JL. PANGKAL PERJUANGAN KM.20267-414520, 0267 - 414524,
4145210267-414524|0267-4145240267-413277 Y Y ALL COVERAGE
929 1027 KLINIK BINA MEDIKA KARAWANG JL. TELUK JAMBE NO 8, KARAWANG BARAT0267-641968 / 08121918055-
412117|-0267 - 641968 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
930 1035 KLINIK MITRA GEMPOLJL. PROKLAMASI NO. 15 KW 8 RT 003 RW. 005 KEL.
TUNGGAKJATI KEC KARAWANG BARAT KAB. KARAWANG,0267- 8451114-|- - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
931 2741 RSIA. MITRA FAMILY-KARAWANGJL. RONGGOWALUYO RT.02/05 DESA SUKAHARJA KEC.
TELUKJAMBE TIMUR, KARAWANG
0267 - 8458327 , 8458328,
8458329|- Y Y ALL COVERAGE
Page 20 of 40
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
932 0083 RS. DEWI SRI JL. ARIF RAHMAN HAKIM, NO.10267-401475, 402855, 406445,
402147|0267-4021470267-404010 Y Y ALL COVERAGE
933 1635 KLINIK MITRA KONDANG UTAMA JL. PENGAIRAN CITRA KEBUN MAS KONDANG KARAWANG 0267-8616923| 0267-8450001 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
934 1835 KLINIK GRIYA MEDIKAPERUM GRIYA KONDANG ASRI BLOK T NO. 01 DESA
KONDANG JAYA KEC. KLARI - KARAWANG TIMUR0267-8619999; 082112039999| 0267-8615309 N Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
935 1058 KLINIK NAFILA MEDIKAJL. PRINGGODANI BLOK J-47 PERUMNAS TELUK JAMBE,
KARAWANG BARAT0267-640020|- 0267-8456419 N Y ALL COVERAGE
936 1059 KLINIK PURI ASIH TELUKJAMBE DUSUN SUKAMULYA, DESA PINAYUNGAN, TELUK JAMBE 0267-646845-|- 0267-646845 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
937 1314 RSIA. DR. DJOKO PRAMONO JL. PANATAYUDA 1, NO.35, KARAWANG BARAT 0267-403009/418818/403744| 0267-411744 Y Y ALL COVERAGE
938 1572 DHARMA DENTAL CLINIC (DDC) JL. KERTABUMI NO 62 KARAWANG 0267-8453633| 0267-403962 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
939 0095 KLINIK GRAHA MEDISJL. RAYA KOSAMBI, NO.23, DUREN KLARI, KARAWANG
TIMUR0267-435527| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
940 0690 KLINIK YAKESTI KARAWANG JL. RAYA KLARI, RT. 04 / 01, GINTUNGKERTA KLARI 0267-432416| 0267-432416 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
941 0691 KLINIK PURWAMEDIKA JL. RAYA TAMELANG NO.53, KERAWANG 0267-433653| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
942 2993 KLINIK & APOTEK KF 79 KARAWANG JL. DEWI SARTIKA II NO.30 KARAWANG 0267-405748| 0267-405748 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
943 2801 LAB. PRODIA KARAWANG JL. KERTABUMI NO. 67 A, KARAWANG 41311. 0267- 403644; 412640| 0267-412640 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
944 1133 RS. MANDAYA(D/H RS.CITO KARAWANG) JL. ARTERI TOL KARAWANG BARAT TELUK JAMBE 0267-414245 / 414264| 0267-414306 Y Y ALL COVERAGE
945 3400 KLINIK GRAHA MEDIS CILAMAYA JL. CILAMAYA DS CILAMAYA KEC CILAMAYA WETAN 0264-340202| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
946 4509 KLINIK KYOAI MEDICAL CENTERGEDUNG THE MANOR LT. 2, JL. SURYA UTAMA KAV.C-1,
KAWASAN INDUSTRI SURYA CIPTA(021) 30424007/8/9| 021-30424010 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
947 3369 APOTIK KIMIA FARMA 343 JL. KERTABUMI NO 12A KARAWANG JAWA BARAT 0267-8453321| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
948 4658 KLINIK INTERNA MEDIKAJL. MELATI NO. 9A RT. 001/ 010, GURO II, KEL.
KARAWANG WETAN, KEC. KARAWANG TIMUR, KARAWANG(0267) 845 2733 / 0812-8586 4765| 2678452733 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
949 2731 RS. ROSELAJL. INTERCHANGE TOL KARAWANG BARAT NO.3 DS
WADAS KEC. TELUK JAMBE(0267) 8637207/8637205| 0267 8367205 Y Y ALL COVERAGE
950 5434 KLINIK AR-RAHMANJL. RAYA PERURI NO. 07, TELUK JAMBE TIMUR,
KARAWANG(0267) 8458155| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
951 0255 RS. BAYUKARTA JL. KERTABUMI, NO.440267-401817/401818/4003510267-
801818|0267-8018180267-404472 Y Y ALL COVERAGE
952 1006RS. CITRA SARI HUSADA (D/H KLINIK INTAN
BAROKAH)
JL. RAYA KOSAMBI-TELAGASARI, KM.3, KLARI,
KARAWANG TIMUR0267-437507/8617972| 0267-438681 Y Y ALL COVERAGE
953 4319 KLINIK & RB NUR ANNISA JL. MANUNGGAL VII NO. 38 PALUMBONSARI, KARAWANG (0267) 405201| - Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
954 2823 RS. LIRA MEDIKAJL. SYECH QURO NO.14 LAMARAN, KARAWANG - JAWA
BARAT(0267) 8452555 / 405 752| (0267) 405 752 Y Y ALL COVERAGE
955 4320 KLINIK SETYA MEDIKAJL. BELAKANG PASAR RT. 02/09 KEL. NAGASARI KEC.
KARAWANG BARAT, KARAWANG(0267) 402025| (0267) 402025 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
956 4699 RSIA. SENTUL CIKAMPEKJL. A. YANI NO . 16 SENTUL KEC. CIKAMPEK, KAB.
KARAWANG(0264) 8389060/ 8386671| (0264) 316096 Y Y ALL COVERAGE
957 1310 KLINIK ANDINA KARAWANG JL. PANCAWATI, NO.5A, KLARI 0267-436568| 0267-438406 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
958 4683 KLINIK SEHAT BAHAGIAJL. PANATAYUDHA I NO. 57 A RT. 02 RW. 03 NAGASARI,
KARAWANG(0267) 414 283| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KUNINGAN
959 3763 PRODIA KUNINGAN JL. ACHMAD YANI NO. 39, KUNINGAN 45511 (0232) 876839| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
960 1345 RS. JUANDA KUNINGAN JL. IR. H. JUANDA NO.207 KUNINGAN 0232-876433/875871| 0232-876433/875871 Y Y ALL COVERAGE
961 1704 RS. SEKAR KAMULYAN JL. RUMAH SAKIT NO 28, CIGUGUR KUNINGAN 0232-873206| 0232-875516 Y Y ALL COVERAGE
MAJALENGKA
962 3658 PRODIA CIDERESJL. RAYA JOMBOL-DAWUAN RT. 01/05, KECAMATAN
DAWUAN, MAJALENGKA 45452(0233)6645488| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PURWAKARTA
963 1620 RS. BHAKTI HUSADA II PURWAKARTAJL. RAYA SADANG SUBANG, KP. KIARA DUA, DS.
CIKUMPAY, KEC. CAMPAKA
0264-
8225344/8225345/081373360783|0264-8225255 Y Y ALL COVERAGE
964 4443 KLINIK MITRA MEDIKA PURWAKARTAJL. MR. DR. KUSUMAATMAJA NO. 13, KEL. CIPAISAN,
PURWAKARTA(0264) 8624195| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
965 1526 RS. AMIRA JL. IPIK GANDAMANAH RT.035 RW.003 MUNJUL JAYA 0264-8221191/92| 0264-8221193/95 Y Y ALL COVERAGE
966 1315 KLINIK MIRACLE GROUP KOMP. ANEKA JASA BLOK AII NO.9-10 KOTA BUKIT INDAH 0264-35166, 351377| 0264-351355 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
967 1057 RSIA. ASRI PURWAKARTA JL. VETERAN CIHIDEUNG NO.15 PURWAKARTA 0264-211680-0811117031|- 0264-219047 Y Y ALL COVERAGE
968 0189 KLINIK AQMA PURWAKARTA JL. IBRAHIM SINGADILAGA, NO.14 0264-200377| 0264-200377 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
969 1043 SILOAM HOSPITAL PURWAKARTA JL. BUNGURSARI NO.1 PO.BOX 167 - Purwakarta0264-8628900/8628911|0264-
2312730264-212674 Y Y ALL COVERAGE
970 1175 KLINIK AQMA PLERED JL. ANJUN NO.96 PLERED 0264-270830| 0264-270830 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
971 4054 RS. KARINA MEDIKA PURWAKARTA KP.KRAJAN RT. 01/01 MARACANG, BABAKAN CIKAO (0264) 8220544| (0264) 8623240 Y Y ALL COVERAGE
972 1545 RS. MH THAMRIN PURWAKARTA JL. BUNGURSARI, NO.36 0264-8222222| 0264-8222223 Y Y ALL COVERAGE
973 0759 KLINIK MEDIKA SEHAT JL. IPIK GANDAMANAH SUKAMULYA 0264-8225017| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
974 3765 PRODIA PURWAKARTA JL. VETERAN NO.96, PURWAKARTA (0264) 8222 633| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
975 2698 KLINIK & APOTEK KF PURWAKARTAJL. VETERAN NO 152 KEL NAGRI KALER PURWAKARTA (
DEPAN INSPECTORAT )0264 8227437| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
976 4763 KLINIK SPESIALIS SILOAM PURWAKARTAJL VETERAN RT. 031/004, KEL. NAGRI KALER,
KEC.PURWAKARTA, JAWA BARAT0264-8628901| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
977 1718 RS. KHUSUS BEDAH RAMA HADIJL. RAYA SADANG - SUBANG , DS CIWANGI BUNGUR SARI
PURWAKARTA0264 - 202136 / 8282295| 0264-8225679 Y Y ALL COVERAGE
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
SUBANG
978 2752 KLINIK MITRA ABADIJL. KAPTEN HANAFIAH NO.3 RT. 98 RW. 27 KEL.
KARANGANYAR, SUBANG0260-418247| 0260-418237 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
979 4325INHOUSE CLINIC PT. DAHANA (KLINIK MITRA
ABADI)JL. RAYA SUBANG, CIKAMURANG KM.12 CIBOGO -SUBANG (0260) 742 3333| (0260) 742 3888 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
980 0191 RS. PERKEBUNAN NUSANTARA 8 SUBANG JL. OTTO ISKANDAR, NO.1, SUBANG
0260-
420406,411632,420306,420436|026
0-411632/4
0260-420391 Y Y ALL COVERAGE
SUKABUMI
981 2892 RS. KARTIKA CIBADAK JL. SILIWANGI NO.139, CIBADAK, SUKABUMI (0266) 7160071| (0266) 535586 Y Y ALL COVERAGE
982 3448 RS. RIDOGALIH JL. GUDANG NO. 24 SUKABUMI 0266-221983| 0266-216161 Y Y ALL COVERAGE
983 1107 RS. BETHA MEDIKA JL. RAYA CISAAT NO.595 SUKABUMI 0266-216422,224128-|- - Y Y ALL COVERAGE
984 1506 RS. KARTIKA MEDICAL CENTER JL. JEND. A.YANI, NO.18 0266-6250902/6250905/6250904| 0266-6250901 Y Y ALL COVERAGE
985 0832 RS. HERMINA SUKABUMI JL. RAYA SUKARAJA RT.003/03, SUKARAJA 0266-6252525/6249292| 0266-235020 Y Y ALL COVERAGE
986 1507 RS. BHAKTI MEDICARE JL. RAYA SILIWANGI, CICURUG 0266-731555| 0266-731899 Y Y ALL COVERAGE
987 0056 RS. ISLAM ASSYIFA JL. JEND. SUDIRMAN, NO. 27
0266-
222663/218672/241463/223742/223
7420266-21343|0266-21343
0266 - 213433 Y Y ALL COVERAGE
SUMEDANG
988 2122 KLINIK PADJADJARAN JATINANGORJL. KOLONEL AHMAD SYAM RT 04 RW 02 DESA SAYANG
KEC. JATINANGOR -BANDUNG022-7797432 / 7781900| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
989 1128 RS. PAKUWON SUMEDANG JL. RD.DEWI SARTIKA NO.17 SUMEDANG 45311 0261-210834/2797773/201132| 0261-210834 Y Y ALL COVERAGE
990 3786 PRODIA SUMEDANG JL. P. GEUSANULUN NO. 111, SUMEDANG 45312 (0261) 201259| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TASIKMALAYA
991 2466 RS. PERMATA BUNDA TASIKMALAYAJL. BRIGJEND HR. WASITA KUSUSMAH NO.1
TASIKMALAYA, JAWA BARAT0265-345650| - Y Y ALL COVERAGE
992 2390 RS. PRASETYA BUNDA TASIKMALAYA JL. IR. H. JUANDA NO. 1 (SIMPANG JATI) 0265320100/0265344477| - Y Y ALL COVERAGE
993 0256 RSI. HJ. SITI MUNIROH TASIKMALAYA JL. TAMAN SARI, GOBRAS, NO.208 0265-323868,327630|0265-327630 0265-327630 Y Y ALL COVERAGE
994 2096 KLINIK & APOTEK KF 195 JL. SUTISNA SENJAYA NO. 191 TASIKMALAYA 0265-311225/311224| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
995 0253 RS. JASA KARTINI JL. OTTO ISKANDARDINATA NO 150265-331808/331641;|0265-
33186410265-331808/331114 Y Y ALL COVERAGE
996 2773 RSB. SAYANG BUNDA JL. N. SUKALAYA I NO.22 0265330841| 0265-330841 Y Y ALL COVERAGE
997 1625 RS. TASIK MEDIKA CITRATAMA (TMC) JL. HZ MUSTOFA NO 310 TASIKMALAYA 0265-322333| 0265-326767 Y Y ALL COVERAGE
998 3203 RSIA. UMMI TASIKMALAYA JL. PASEH NO.10 - TASIKMALAYA 0265-329126| - Y Y ALL COVERAGE
999 2935 LAB. PRODIA TASIKMALAYA JL. RE MARTADINATA NO 9 0265-2353080| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1000 4798 RSIA. BUNDA AISYAH JL. R. E. MARTADINATA NO. 200B TASIKMALAYA (0265) 7297400; 7297401| - Y Y ALL COVERAGE
1001 2106 KLINIK & APOTEK KF 404 JL. R.A MARTADINATA NO. 87 TASIKMALAYA 0265-340515| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
JAWA TENGAH
BANYUMAS
1002 3171 RSU. WIRADADI HUSADA JL. MENTERI SUPENO NO. 25 SOKARAJA BANYUMAS 0281-6846225| 0281-6846371 Y Y ALL COVERAGE
BATANG
1003 3360 RS. QOLBU INSAN MULYA (QIM)JL. URIP SUMOHARDJO SAMBONG-BATANG, JAWA
TENGAH0285-4495222| 0285-4495224 Y Y ALL COVERAGE
BOYOLALI
1004 3276 LAB. PRODIA BOYOLALI JL. PANDANARAN NO. 252, BOYOLALI 08122895310| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1005 1661 RS. PKU AISYIYAH BOYOLALI JL. PASAR SAPI BARU SINGKIL 0276-322898/3293400| 0726-3293400 Y Y ALL COVERAGE
BREBES
1006 2292 RS. BHAKTI ASIH BREBESJL. PANGERAN DIPONEGORO NO 125 PESANTUNAN,
BREBES0283-673481/671279| 0283-671391 Y Y ALL COVERAGE
1007 1664 RS. DEDY JAYA JL. A. YANI NO 57 BREBES 0283-672145| 0283-672525 Y Y ALL COVERAGE
BUMIAYU
1008 3173 RSU. ALLAM MEDICA BUMIAYU JL. DIPONEGORO NO. 609, JATISAWIT BUMIAYU 0289-430822| - Y Y ALL COVERAGE
1009 1889 RS. MUHAMMADIYAH SITI AMINAH JL. DIPONEGORO, BUMIAYU 0289-432209/430683| 0289-430683 Y Y ALL COVERAGE
CEPU
1010 3268 LAB. PRODIA CEPU JL. PEMUDA NO. 41 B, CEPU 082331833027| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1011 1438 RS. MUHAMMADIYAH CEPU JL. RONGOLAWE, NO.137 0296-421727| 0296424678/424569 Y Y ALL COVERAGE
CILACAP
1012 3278 LAB. PRODIA CILACAP JL. S. PARMAN NO. 33 CILACAP 0282-5253314| - N Y GP,LAB
1013 4744 KLINIK CAHAYA HUSADAJL. RAJIMAN NO.68 SIDANEGARA, KEC. CILACAP TENGAH,
CILACAP 53223(0282)5227128| -
N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1014 2866 RSUD. CILACAP JL. JEND GATOT SUBROTO NO. 28 CILACAP 0282-533010| 0282-520755 Y Y ALL COVERAGE
1015 4165 RS. APRILLIA JL. JEND GATOT SUBROTO NO.95 CILACAP 0282-536307| 0282-521144 Y Y ALL COVERAGE
1016 2696 KLINIK & APOTEK KF 89 JL. GATOT SUBROTO NO.59, CILACAP 0282 535293| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1017 3526 KLINIK PRATAMA KIMIA FARMA CILACAP JL. GATOT SUBROTIO NO. 59 CILACAP 0282-535293| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1018 1005 KLINIK DR TUTUK JL. PERINTIS KEMERDEKAAN 21 0282-545921-|- - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1019 1152 RS. SANTA MARIA CILACAP JL. JEND.A.YANI NO.38 CILACAP (0282) 534859, 521725| (0282) 531296 Y Y ALL COVERAGE
1020 0975 RS. ISLAM FATIMAH CILACAP JL. H JUANDA NO.20 0282-542396|- 0282-541065/5452151 Y Y ALL COVERAGE
GOMBONG
1021 1243 RS. PALANG BIRU JL. KARTINI, NO.37 0287-471290/471762| 0287-473221/471762 Y Y ALL COVERAGE
1022 3327 RS. PKU MUHAMMADIYAH GOMBONG JL. YOS SUDARSO NO.461,GOMBONG 0287-471780| - Y Y ALL COVERAGE
JEPARA
1023 3959 RSI. SULTAN HADLIRIN JEPARA JL. RAYA JEPARA BANGSRI KM 3 KUWASEN, JEPARA (0291) 591507| (0291) 4295554 Y Y ALL COVERAGE
1024 3368 RSUD. KARTINI JEPARAJL. KH. WAHID HASYIM NO. 175 BAPANGAN, JEPARA,
JAWA TENGAH0291-598180/591175| 0291-591145 Y Y ALL COVERAGE
1025 3269 LAB. PRODIA JEPARA JL. MH. THAMRIM NO. 14 JEPARA 0291598808| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KENDAL
1026 1666 RSI. MUHAMMADIYAH KENDAL JL. AR RAHMAH NO 17 WELERI 0294-641870 / 0294-643756| 0294-644150 Y Y ALL COVERAGE
KLATEN
1027 0754 RS. ISLAM KLATEN JL. RAYA SOLO KM.4 0272-322252|- 0272-332422 Y Y ALL COVERAGE
1028 3273 LAB. PRODIA KLATEN JL. PEMUDA SELATAN NO. 85 KLATEN 081931783130| - N Y GP,LAB
1029 1519 RSU. PKU MUHAMMADIYAH DELANGGU JL. DELANGGU UTARA, NO.19 0272-551051| 0272-554041 Y Y ALL COVERAGE
1030 1441 RS. CAKRA HUSADA KLATEN JL. MERBABU, NO.7 0272-321123-322386-322394| 0272-329029 Y Y ALL COVERAGE
KUDUS
1031 3163 LAB. PRODIA KUDUS JL. WAHID HASYIM NO.75, KUDUS -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1032 0146 RS. MARDI RAHAYU KUDUS JL. AKBP.R. AGIL KUSUMADYA, NO.110 0291-434707-12/435582/443581| 0291-438398,434711 Y Y ALL COVERAGE
1033 3259LAB. CITO (JL. AKBP AGIL KUSUMADYA NO. 7
)JL. AKBP AGIL KUSUMADYA NO. 7 0291-4251979| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
MAGELANG
1034 0335 RS. HARAPAN MAGELANG JL. P. SENOPATI, NO.11 0293-364033-35| 0293-364036-37 Y Y ALL COVERAGE
1035 3286 LAB. CITO MAGELANG JL. TENTARA PELAJAR NO 126 MAGELANG 0293 363763| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1036 3161 LAB. PRODIA MAGELANG JL. AHMAD YANI NO.36 A, MAGELANG 0293-364323| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1037 1165 RSIA. GLADIOOL JL. KENANGA, NO.4-6 0293-362702| - Y Y ALL COVERAGE
1038 1132 RS. LESTARI RAHARJA JL. MAYJEN SUTOPO NO.5 0293-362225| 0293-362649/311512 Y Y ALL COVERAGE
PATI
1039 1534 RS. MITRA BANGSA JL. KOL.SUGIYONO, NO.75 PATI 0295-382555| 0295-4191994 Y Y ALL COVERAGE
1040 4455 RSU FASTABIQ SEHATJL. RAYA PATI - TAYU KM.3 TAMBAHARJO, PATI, JAWA
TENGAH(0295) 4199008| - Y Y ALL COVERAGE
1041 1299 KELUARGA SEHAT HOSPITAL JL. P.SUDIRMAN NO.9 MARGOREJO 0295-386111| 0295-384422 Y Y ALL COVERAGE
PEKALONGAN
1042 3227 LAB. CITO PEKALONGAN JL. K.H. MANSYUR NO.33 PEKALONGAN 0285-422458| 0285-422458 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1043 2694 KLINIK & APOTEK KF 16 JL. IMAM BONJOL, NO.16 A, PEKALONGAN 0285-421402| 0285-423322 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1044 0120 RS. SITI KHODIJAH PEKALONGAN JL. BANDUNG, NO.39-47 KOTA PEKALONGAN0285-
422845,425138,423590,424919|0285-425138 Y Y ALL COVERAGE
1045 1220 RS. BUDI RAHAYU PEKALONGAN JL. BARITO, NO.5 PEKALONGAN 0285 - 423491/424340| 0285-423002 Y Y ALL COVERAGE
PEMALANG
1046 1219 RSU. SANTA MARIA PEMALANG JL. PEMUDA NO.24 0284 - 321251/321426| 0284 - 322335 Y Y ALL COVERAGE
1047 4093 RS. PRIMA MEDIKA PEMALANG JL. SLAMET RIYADI NO. 321 MULYOHARJO 0284 - 324221 / 322448| - Y Y ALL COVERAGE
PURBALINGGA
1048 3277 LAB. PRODIA PURBALINGGA JL. LETJEND SUPRAPTO NO. 17 B, PURBALINGGA 08112616123| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1049 1888 RSU. HARAPAN IBU PURBALINGGA JL. MAYJEND SOENGKONO NO. 1 0281-892222/982277| - Y Y ALL COVERAGE
PURWODADI
1050 1226 RS. PANTI RAHAYU JL. LETJEND. SUPRAPTO NO.6 0292 - 421087-422325| 0292-421370/425095 Y Y ALL COVERAGE
PURWOKERTO
1051 0201 RSU. BUNDA PURWOKERTO JL. PRAMUKA, NO.2490281-635424/0281-632514|0281-
6325140281-632514 Y Y ALL COVERAGE
1052 4665 RSKB. JATIWINANGUN JL. JATIWINANGUN NO. 54, PURWOKERTO (0281) 638169| 081-623938 Y Y ALL COVERAGE
1053 3131 LAB. CITO PURWOKERTO JL. PRAMUKA 798 RT 7/1 PURWOKERTO 0281-637362; 637538| 0281-637583 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1054 1448 RSIA. BUNDA ARIF PURWOKERTO JL. JATIWINANGUN, NO.16 PURWOKERTO 0281-636555| - Y Y ALL COVERAGE
1055 1351 RS. ORTHOPAEDI PURWOKERTO JL. SOEPARDJO ROESTAM NO. 99 PURWOKERTO 0281-6844166| 0281-6844188 Y Y ALL COVERAGE
1056 2094 APOTEK KIMIA FARMA 133 PURWOKERTO JL. JEND. SUDIRMAN TIMUR NO. 435 PURWOKERTO 0281-638546| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1057 1447 RSU. ANANDA PURWOKERTO JL. PEMUDA, NO.30 0281-631435-636417| 0281-640226/632146 Y Y ALL COVERAGE
1058 2204 LAB. PRODIA PURWOKERTO JL. LETJEN S.PARMAN NO:946 A, PURWOKERTO 0281-642448| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1059 2095 KLINIK & APOTEK KF FAJAR SEHAT JL. R.A WIRIATMAJA NO. 37 PURWOKERTO 0281-637247| 0281-640760 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 23 of 40
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
PURWOREJO
1060 1908 RS. PALANG BIRU KUTOARJO JL. MADITOMO 17, KUTOARJO-PURWOREJO 0275-641425| - Y Y ALL COVERAGE
1061 3272 LAB. PRODIA PURWOREJO JL. JENDRAL AHMAD YANI NO. 22 B PURWOREJO 081914336261| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1062 4971 RS. ISLAM PURWOREJO JL. MAGELANG KM. 2, KEC. LOANO, KAB. PRUWOREJO (0275) 3255470| (0275) 325 570 Y Y ALL COVERAGE
1063 1131 RS. PKU MUHAMMADIYAH PURWOREJO JL. BRIGJEND KATAMSO NO.144 A PURWOREJO 0275-325260| 0275-324776 Y Y ALL COVERAGE
SALATIGA
1064 3160 LAB. PRODIA SALATIGA JL. BRIGJEND.SUDIARTO NO.18 A, SALATIGA 50721 0298311371| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1065 3350 APOTEK KIMIA FARMA SALATIGA JL. BRIGJEN SUDIARTO NO. 30 SALATIGA 0298-325350| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1066 1145 RS. PURI ASIH JL. JEND. SUDIRMAN NO.169 SALATIGA 0298-323209/0298-312049| 0298-322898/311466 Y Y ALL COVERAGE
SEMARANG
1067 0053 RS. ROEMANI MUHAMMADIYAH JL. WONDRI, NO.22 024 - 8444623| 024-8415752 Y Y ALL COVERAGE
1068 0050 RS. PANTI WILASA DR. CIPTO JL. DR. CIPTO, NO.50 024 - 3546040, 3557428| 024-3546042 Y Y ALL COVERAGE
1069 0299 RSU. HERMINA PANDANARAN SEMARANG JL. PANDANARAN NO.24 024-8411112/8442525| 024-8449077 Y Y ALL COVERAGE
1070 0182 RS. ISLAM SULTAN AGUNG JL. KALIGAWE KM.4 024-6580019| 024-6581928 Y Y ALL COVERAGE
1071 0901 RS. BANYUMANIK JL. BINA REMAJA NO.61024-7471519/024-7462181|024-
7462181024-7462181 Y Y ALL COVERAGE
1072 0160 RS. ST. ELISABETH - SEMARANG JL. KAWI NO. 1 024-8310076/ 8310035| 024-8413373 Y Y ALL COVERAGE
1073 0377 RS. TELOGOREJO JL. KH. AHMAD DAHLAN024 - 8446000/8448448|024-
8446000024 - 8449660 Y Y ALL COVERAGE
1074 1806 RSUP. DR KARIADI JL. DR SUTOMO NO.16 SEMARANG, JAWA TENGAH 024-8413476/8413993| 024-8318617 Y Y ALL COVERAGE
1075 2246 APOTEK KIMIA FARMA 17 JL. TENTARA PELAJAR NO. 16 A, SEMARANG 024-8447245| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1076 2238 KLINIK & APOTEK KF 18 JL. PEMUDA NO. 135 SEMARANG 024-3545101/3541510/3518913| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1077 2168 APOTEK FARMARIN SEMARANG JL. KALIGARANG NO. 2D 024-8450558| 024-8450558 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1078 1450 RS. PERMATA MEDIKA JL. MR.MOCH. ICHSAN, NO.93-97, NGALIYAN 024-7625005/7618800/7626571| 024-7621733 Y Y ALL COVERAGE
1079 2692 KIMIA FARMA 178 JL. BRIG.SUDIARTO,462 E (MAJAPAHIT LAMA) 024 6716235| -- N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1080 2693 KLINIK & APOTEK KF 71 JL. DR.SOETOMO NO.3 , SEMARANG 024 3520763| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1081 3162LAB. PRODIA SEMARANG (JL. JEND
SUDIRMAN )JL. JENDRAL SUDIRMAN NO.121 SEMARANG 024-7621757| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1082 3215 RS. WILLIAM BOOTH SEMARANG JL. S. PARMAN NO. 5 SEMARANG 024-8411800| Y Y ALL COVERAGE
1083 4379 KLINIK MATA NUSANTARA (SEMARANG)JL. AHMAD YANI NO. 164, KEL. KARANG KIDUL, KEC.
SEMARANG TENGAH(024) 8645 6688| (024) 841 7770 N Y GP,OP
1084 3261KIMIA FARMA 153 (JL. JATI RAYA
BANYUMANIK)JL. JATI RAYA BANYUMANIK, SEMARANG 024-7464268| 024-7464268 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1085 3262 KIMIA FARMA 259 (JL. FATMAWATI) JL. FATMAWATI NO. 42, SEMARANG 024-76928544| 024-76928544 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1086 3264 KIMIA FARMA 271 MEDITAMA (JL. AHMAD)JL. KH. AHMAD DAHLAN NO. 9, KEL. BENDUNGAN, KEC.
GAJAHMUNGKUR024-8455323| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1087 3265 KLINIK & APOTEK 324 (JL. RAYA NGALIAN)JL. RAYA NGALIYAN , KEL. TAMBAK AJI, KEC.NGALIYAN
SEMARANG024-7612049| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1088 3349 APOTEK KIMIA FARMA 203 UNGARAN JL. DIPENOGORO 212 UNGARAN 024-76914353| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1089 3243 LAB.PRODIA SETIABUDI SEMARANG RUKO SETIABUDI NO.8 JL. SETIABUDI 119 D 024-7479369/081390967979| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1090 3245 LAB. CITO (JL. INDRAPRASTA NO. 81 A) JL. INDRAPRASTA NO. 81 A SEMARANG 024-3556853| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1091 3246 LAB. CITO ( JL. SETIABUDI ) JL. SETIABUDI SEMARANG 024-7461645| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1092 3247 LAB. CITO ( JL. DR. CIPTO ) JL. DR. CIPTO 14A SEMARANG 024-3515374| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1093 3260 KIMIA FARMA 19 (JL. SULTAN AGUNG)JL. SULTAN AGUNG KOMPL. PERTOKOAN R A/15
SEMARANG024-8315248| 024-8315795 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1094 4705 KLINIK KITA MANGKANG (DR. MOEZ) JL. RAYA MANGKANG KM.92 SEMARANG (024) 8663782| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1095 3218 KLINIK KITA KALIPANCUR (DR MOEZ)JL. ABDULRAHMAN SALEH KAV. 783 KALIPANCUR,
SEMARANG024-7624455/ 085641869731| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1096 4457 RSIA GUNUNG SAWOJL. GUNUNG SAWO NO. 21 RT.08 RW. 04, KEL. PETOMPON,
KEC. GAJAHMUNGKUR, SEMARANG024-8315171| (024) 8412320; Y Y ALL COVERAGE
1097 2969 RS. HERMINA BANYUMANIKJL. JENDRAL POLISI ANTON SOEDJARWO NO. 195 A,
SEMARANG 50263(024) 7648 8989| (024) 7647 9080 Y Y ALL COVERAGE
1098 3230 KLINIK KITA KEDUNGMUNDU (DR MOEZ)JL. KEDUNGMUNDU RUKO GRAHA WAHID NO. 7,
SEMARANG-| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1099 3231KLINIK KITA IBNU SIENA PUSPONJOLO (DR
MOEZ)JL. PUSPONJOLO TENGAH RAYA NO. 65, SEMARANG -| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1100 3232KLINIK KITA IBNU SIENA NGALIYAN (DR
MOEZ)JL. PROF HAMKA RUKO SEGITIGA EMAS B 7, SEMARANG -| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1101 3233 KLINIK KITA CANGKIRAN (DR MOEZ) JL. JATI KALANGAN RUKO PURI DELTA ASRI, SEMARANG -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1102 4373 KLINIK RAFAEL JL. PLAMPITAN NO.33, SEMARANG (024) 3513888| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1103 2822 RS. COLUMBIA ASIA SEMARANG JL. SILIWANGI NO. 143 SEMARANG (024) 762 9999/86462020| (024) 7667 4228 Y Y ALL COVERAGE
1104 3267 KIMIA FARMA 374 (JL. TELOGO SARI)JL. TLOGOSARI RAYA NO. 1 KAV. 2, KEL. TLOGOSARI
KULON, KEC. PEDURUNGAN, SEMARANG024-6709192| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 24 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1105 3217 KLINIK KITA TEMBALANG (DR MOEZ) JL. NGESREP TIMUR 5/36 BANYUMANIK, SEMARANG 024-7472220 / 085640398938| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1106 2239 LAB. PRODIA SEMARANG JL. MT. HARYONO NO:882 SEMARANG 024-8444331| 024-8414308 N Y GP,LAB
1107 5430 RSIA ANUGERAH SEMARANG JL. KALISARI BARU NO.5-7 024-8313543| 024-8443016 Y Y ALL COVERAGE
1108 1663 RS. KEN SARAS JL. SOEKARNO HATTA KM 029 024-6922269| 0298-522706 Y Y ALL COVERAGE
SLAWI
1109 1665 RS. ADELLA JL. PROF MOH YAMIN NO. 77 SLAWI 0283-491154/491773| 0283-491354 Y Y ALL COVERAGE
SOLO
1110 0212 RS. ISLAM KUSTATI JL. KAPTEN MULYADI NO.249 0271 - 643013| 0271-634823 Y Y ALL COVERAGE
1111 2907 RS. HERMINA SOLO JL. KOL SUTARTO NO. 16 JEBRES SOLO 0271-638989| 271 Y Y ALL COVERAGE
1112 3354 APOTEK KIMIA FARMA YOSODIPURO 252 JL. NO.111B, SOLO -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1113 3280 LAB. KLINIK KIMIA FARMA SURAKARTA JL. ADISUCIPTO NO. 70 SURAKARTA 0271-727886| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1114 3307 KLINIK & APOTEK KF 63 SOLO JL. ADISUCIPTO NO. 70 SURAKARTA 0271-718014| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1115 3279 LAB. CITO SOLO JL. YOSODIPURO NO.64 SURAKARTA 0271-2500055| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1116 2181 APOTEK FARMARIN SOLO JL. GREMET NO.3 RT 007/11 MANAHAN 085727427423| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1117 2373 LAB. PRODIA SOLO JL. RONGGOWARSI. TO NO. 143 SOLO 57131 0271-646378| 0271-638779 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1118 0118 RS. DR. OEN SOLO BARU KOMP. PERUMAHAN SOLO BARU, GROGOL, SUKOHARJO 0271-620220| 0271-622555/660935 Y Y ALL COVERAGE
1119 0214 RS. DR. OEN SURAKARTA(KANDANG SAPI) JL. BRIGJEN KATAMSO NO.55, KANDANG SAPI 0271-643139| 0271-642026 Y Y ALL COVERAGE
1120 0745 RS. ISLAM SURAKARTA JL. A YANI PABELAN KARTASURA, SOLO0271-7105710271-725134|0271-
7251340271-710572 Y Y ALL COVERAGE
1121 0746 RS. PKU MUHAMMADIYAH SURAKARTA JL. RONGGOWARSITO NO130, SURAKARTA 0271-714578| 0271-717012 Y Y ALL COVERAGE
1122 1179 RS. BRAYAT MINULYA JL. DR.SETIABUDI NO.106 SURAKARTA 0271-716646,710170| 0271-727309/712181 Y Y ALL COVERAGE
1123 1483 RS. PANTI WALUYO SURAKARTA JL. JEND.A.YANI NO.1 0271-712077| 0271-729125 Y Y ALL COVERAGE
SRAGEN
1124 3353 APOTEK KIMIA FARMA SRAGEN JL. SUKOWATI NO.440A, SRAGEN -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1125 3275 LAB. PRODIA SRAGEN JL. KOLONEL SUGIYONO NO. 8, WIDORO, SRAGEN 0271-890263| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SUKOHARJO
1126 1178 RS. NIRMALA SURI JL. RAYA SOLO KM 9 SUKOHARJO 0271-592192| - Y Y ALL COVERAGE
1127 3355 APOTEK KIMIA FARMA SUKOHARJO JL. VETERAN NO.11 SUKOHARJO 0271-590411| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TEGAL
1128 3219 LAB. PRODIA TEGAL JL. KAPTEN SUDIBYO NO. 136 TEGAL 0283-358673| 0283-353664 N Y GP,LAB
1129 3220 LAB. CITO TEGAL JL. GAJAH MADA NO. 79 TEGAL 0283-353402| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1130 1540 RS. MITRA KELUARGA TEGAL JL. SIPELEM, NO.4, KEMANDUNGAN, TEGAL BARAT 0283-340399/ 340999| 0283-340902 Y Y ALL COVERAGE
1131 0753 RS. ISLAM HARAPAN ANDA JL. ABABIL NO.420283-355717 /0283-359900 / 0283-
358244|0283-351263 Y Y ALL COVERAGE
1132 2093 APOTEK KIMIA FARMA 97 TEGAL JL. MAYJEN SUTOYO NO. 44 TEGAL 0283-35473| 0283-3355765 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1133 3359 RSIA. PALARAYA JL. PALARAYA NO. 11 A TEGAL 0283-356009| - Y Y ALL COVERAGE
TEMANGGUNG
1134 4508 RS. MUHAMMADIYAH TEMANGGUNG JL. RAYA KEDU KM.2 KALISAT TEMANGGUNG 56253 (0293) 596704, 596700, 4909900| (0293) 598700 Y Y ALL COVERAGE
1135 1144 RS. NGESTI WALUYO JL. PAHLAWAN-PARAKAN 0293-596008| 0293-596410 Y Y ALL COVERAGE
1136 4519 PRODIA TEMANGGUNG RUKO PANDEAN, JL MT. HARYONO - TEMANGGUNG 0293-4960160| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
WONOGIRI
1137 3274 LAB. PRODIA WONOGIRI JL. JEND. ACHMAD YANI NO. 58 WONOGIRI 08122583522| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
WONOSOBO
1138 4127 LAB. PRODIA WONOSOBO JL. KAUMAN NO. 15, WONOSOBO ( PERTIGAAN MANGLI ) 0286-325275| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
JAWA TIMUR
BANGIL
1139 0700 RS. ISLAM MASYITHOH JL. A. YANI, NO.6 0343-741018| 0343-742425 Y Y ALL COVERAGE
BANGKALAN
1140 3841 APOTEK KIMIA FARMA TRUNOJOYO 419 JL. TRUNOJOYO NO.75A BANGKALAN 0313095459| 313095459 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1141 3840 APOTEK KIMIA FARMA 163 JL. JOKOTOLE NO.5 BANGKALAN 0313091016| 313091016 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1142 3595 RS. LUKAS JL. KH.MOH.KHOLIL 36A 031-3095148| 031-3061367 Y Y ALL COVERAGE
Page 25 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
BANYUWANGI
1143 1429 RS. YASMIN BANYUWANGI JL. LETKOL ISTIQLAL NO.80-84 0333-424671| -0333-418219 Y Y ALL COVERAGE
1144 0726 RS. ISLAM FATIMAH BANYUWANGI JL. JEMBER, NO.25 0333-421451| 0333-423204/417929 Y Y ALL COVERAGE
1145 0724 RS. AL-HUDA JL. DIPONEGORO, NO.65, GENTENG0333-
842033/844682/845248/842118|0333-842036/38 Y Y ALL COVERAGE
1146 4130 RSIA. PKU MUHAMMADIYAH ROGOJAMPI JL. PANGERAN DIPONEGORO NO. 20, ROGOJAMPI 0333-631149| - Y Y ALL COVERAGE
1147 4065 RS. NAHDLATUL ULAMA BANYUWANGIJL. RAYA MANGIR NO. 09 KEC. ROGOJAMPI KAB.
BANYUWANGI0333-632965| 0333-632965 Y Y ALL COVERAGE
BLITAR
1148 0269 RS. KATOLIK BUDI RAHAYU BLITAR JL. JEND. A.YANI NO. 18 BLITAR 0342-801066/802316/807802| 0342-806509/804284 Y Y ALL COVERAGE
1149 3807 RS. UMUM AMINAH BLITAR JL. VETERAN NO. 39, KEPANJEN, KIDUL BLITAR 66111 0342-816304/816305| 0342-816527 Y Y ALL COVERAGE
BOJONEGORO
1150 0731 RS. AISYIYAH BOJONEGORO JL. HASYIM ASHAARI, NO.17 0353-881748/885978| 0353-885978 Y Y ALL COVERAGE
1151 1032 RS. PKU MUHAMMADIYAH KALITIDU JL. RAYA KALITIDU, NO.266, KALITIDU 0353-511731/512066-|- 0353-511678/512066 Y Y ALL COVERAGE
BONDOWOSO
1152 3892 RS. MITRA MEDIKA BONDOWOSO JL. HOS COKROAMINOTO 98, BONDOWOSO 0332-421981; 423800| 0332 429601 Y Y ALL COVERAGE
GRESIK
1153 4053 RS. PETROKIMIA GRESIK DRIYOREJO JL. RAYA LEGUNDI KM 5 031-8986701, 8981779, 8981778| 031-8986700 Y Y ALL COVERAGE
1154 0596 RS. SEMEN GRESIK JL. RA. KARTINI, NO.280 GRESIK 031 - 3987840,3989478,3975847| 031-3987842 Y Y ALL COVERAGE
1155 4235 RS. FATHMA MEDIKA GRESIK JL. PENDOPO NO. 45, SEMBAYAT, MANYAR, GRESIK (031) 394 3500| - Y Y ALL COVERAGE
1156 3648 RSUD. IBNU SINA KAB. GRESIK JL. DR. WAHIDIN SH NO.243B, GRESIK 031-3951239| - Y N H&S,MAT
1157 4966 KLINIK MEDIS PUSURA MENGANTIRUKO MENGANTI MAS BLOK U-2, JL RAYA BRINGKANG,
MENGANTI, GRESIK031-5471707| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1158 4522 RS. SURYA MEDIKAJL. LABAN KULON NO. 58 MENGANTI GRESIK 61174, JAWA
TIMUR(031) 7914025| 031-7911889 Y Y ALL COVERAGE
1159 1427 RS. PETROKIMIA GRESIK JL. JEND. A.YANI NO.69
031-
3988877/3990994/3978658/3977666
|
031-3980008/3981232 Y Y ALL COVERAGE
1160 1923 RS. PETROKIMIA GRESIK GRHA HUSADA JL. PADI NO. 3 KOMPLEK PT PETROKIMIA GRESIK 031-3984465,3973400,3793401| 031-3972623 Y Y ALL COVERAGE
1161 3842 KLINIK & APOTEK KF 164 JL. R.A KARTINI NO.150-152 0313984783| 313984783 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1162 2610 RS. WATES HUSADAJL. RAYA WATES UTARA KEDUNGPRING,
BALONGPANGGGANG - GRESIK(031) 7922351| - Y Y ALL COVERAGE
JEMBER
1163 0725 RS. PERKEBUNAN (PTPN) X JEMBER JL. BEDADUNG, NO.2 JEMBER
0331-
487104,485415,426873,485912,410
7480331-487226|0331-487226
0331-485912 Y Y ALL COVERAGE
1164 1685RSU. KALIWATES PT PERKEBUNAN
NUSANTARA XIIJL. DIAH PITALOKA NO 1 JEMBER
0331-
3137525/483567/488964/485967/48
9100|
0331-489100 Y Y ALL COVERAGE
1165 2077 KLINIK & APOTEK KF 241 JEMBER JL. PANGLIMA SUDIRMAN NO. 46 JEMBER 0331-489885| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1166 2076 KLINIK & APOTEK KF 62 JEMBER JL. GAJAH MADA 171 JEMBER 0331-489020| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1167 1428 RS. BINA SEHAT JL. JAYANEGARA NO.7 0331-422701/424304/421713| 0331-428390 Y Y ALL COVERAGE
1168 3530 RS. CITRA HUSADA JL. TERATAI NO.22 JEMBER (0331) 486200| (0331) 427088 Y Y ALL COVERAGE
JOMBANG
1169 1849 RSIA. MUSLIMAT JOMBANG JL. URIP SUMOHARJO NO 34 JOMBANG 0321-872200/877600/869434| 0321-854991 Y Y ALL COVERAGE
1170 0978 RS. KRISTEN MOJOWARNO JL. MERDEKA NO.59, MOJOWARNO 0321-495093-|- 0321-492200/495440 Y Y ALL COVERAGE
1171 1880 RS. AIRLANGGA JOMBANG JL. AIRLANGGA NO 50 C JELAKOMBO, JOMBANG 0321-861577| 0321-862194 Y Y ALL COVERAGE
1172 0810 RS. DR. MOEDJITO DWIDJOSISWOJO JL. HAYAM WURUK, NO.9 JOMBANG 0321-864308,6977788,855555| 0321-877276 Y Y ALL COVERAGE
1173 5425 RS. NAHDLATUL ULAMA JOMBANG JL. KH. HASYIM ASHARI NO.211 0321-878700| 0321-878700 Y Y ALL COVERAGE
1174 1966 RS. PELENGKAP MEDICAL CENTER JL. JUANDA NO. 03 JOMBANG 0321-877945 / 869826| - Y Y ALL COVERAGE
KEDIRI
1175 0977 RS. BAPTIS KEDIRI JL. BRIDJEN POLLBH PRANOTO NO.1 0354-682170, 683578, 684172-|- 0354-681173 Y Y ALL COVERAGE
1176 3612 PRODIA KEDIRI JL. KARTINI NO. 18, KEDIRI 64123 (0354) 698960| (0354) 698961 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1177 1430 RS. AURA SYIFA JL. JOYOBOYO NO.42 DLOPO 0354-671939| 0354-696033/641939 Y Y ALL COVERAGE
1178 1998 KLINIK & APOTEK KF 75 KEDIRI JL. JAKSA AGUNG SUPRAPTO NO. 25 KEDIRI 0354-773384/ 694913| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1179 2075 KLINIK & APOTEK KF 151 KEDIRI JL. STASIUN NO. 47 KEDIRI 0354-694913| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1180 0248 RS. HVA TOELOENGREDJO JL. A. YANI NO. 25 PARE 0354-391047,391145| 0354-392883 Y Y ALL COVERAGE
1181 4680 RS. MUHAMMADIYAH SITI KHODIJAH KEDIRIJL. DR. SOETOMO 322 SUKOREJO, KEC. GURAH, KAB.
KEDIRI, JAWA TIMUR(0354) 545481; 546593| (0354) 548838 Y Y ALL COVERAGE
1182 1599RS. MUHAMMADIYAH AHMAD DAHLAN
KEDIRIJL. GATOT SUBROTO NO 84 KEDIRI 0354-773115/770182| 0354-776318/773736 Y Y ALL COVERAGE
1183 3828 APOTEK KIMIA FARMA SMAN II PARE JL. PAHLAWAN KUSUMA BANGSA 28 PARE 0354-390006| 0354-390006 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 26 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
LAMONGAN
1184 4765 RS. KH. ABDURRAHMAN SYAMSURI (ARSY) JL. RAYA DEANDLES KM. 74 PACIRAN LAMONGAN (0322) 666626| (0322) 666626 Y Y ALL COVERAGE
1185 1199 RS. MUHAMMADIYAH LAMONGAN JL. JAKSA AGUNG SUPRAPTO 0322-322834| 0322-314048 Y Y ALL COVERAGE
1186 4782 RS. ISLAM NASHARUL UMMAH JL. MERPATI NO. 62, KEC. LAMONGAN, KAB. LAMONGAN 0322-321522| - Y Y ALL COVERAGE
LUMAJANG
1187 2724 RS. ISLAM LUMAJANG JL. KYAI MUKSIN 19 LUMAJANG 0334-887999/893535| (0334) 887778 Y Y ALL COVERAGE
1188 1247 RS. WIJAYA KUSUMA JL. A. YANI, NO.149, LUMAJANG 0334-891325| 0334-888844 Y Y ALL COVERAGE
MADIUN
1189 1183 RS. SITI AISYAH MADIUN JL. MAYJEN SUNGKONO, NO.38 0351-464822/451843| 0351-464009 Y Y H&S,MAT
1190 3421 LAB. PRODIA MADIUN JL. SULAWESI NO.9 MADIUN 0351453344| - N Y GP,LAB
1191 3200 RS. GRIYA HUSADA MADIUN JL. MAYJEND PANJAITAN NO.22 MADIUN 0351 - 472801 / 472802 / 472803| 0351 475900 Y Y ALL COVERAGE
1192 3425 KLINIK & APOTEK KF 76 JL. JAWA NO.14 0351-453381| 0351-453381 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1193 0722 RS. SANTA CLARA JL. BILITON, NO.15 0351-462688/452770/464571| 0351-455780/466509 Y Y ALL COVERAGE
MALANG
1194 0815 RS. PANTI WALUYA SAWAHAN JL. NUSAKAMBANGAN NO.5 0341-362017,366033,361507| 0341-354068 Y Y ALL COVERAGE
1195 0708 RS. LAVALETTE JL. W.R. SUPRATMAN, NO.10 0341-470805/482612| 0341-470804 Y Y ALL COVERAGE
1196 1326 RS. WAVA HUSADA KEPANJEN JL. PANGLIMA SUDIRMAN NO.99A KEPANJEN 0341-393000| 0341-398398 Y Y ALL COVERAGE
1197 1325 RS. MARSUDI WALUYO JL. RAYA MONDOROKO KM.9 SINGOSARI 0341-458974| 0341-451579 Y Y ALL COVERAGE
1198 1252 RS. ISLAM MALANG ( UNISMA ) JL. MAYJEND HARYONO NO. 139 0341-551356,580798,565448| 0341-551257 Y Y ALL COVERAGE
1199 3814 KIMIA FARMA 453 SUTOYO MALANG JL. LETJEN SUTOYO NO. 107 MALANG 0341478382| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1200 3815 KIMIA FARMA NO.245 BATU JL. DIPONEGORO NO. 93 BATU MALANG -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1201 3816 KIMIA FARMA NO. 210 MALANG JL. TUMENGGUNG SURYO NO. 25 MALANG 0341423930| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1202 3817 KIMIA FARMA NO. 187 MALANG JL. M.T. HARYONO NO. 110 MALANG 0341553283| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1203 3818 KIMIA FARMA NO. 150 MALANG JL. SELAT SUNDA 1 D NO. 25 MALANG 0341713091| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1204 3820 KIMIA FARMA NO. 36 MALANG JL. IJEN NO. 88 MALANG 0341359677| 341359678 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1205 3164 LAB. PRODIA MALANG JL. MERBABU NO.10, MALANG 0341-366042| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1206 0252 RS. ISLAM AISYIYAH MALANG JL. SULAWESI, NO.16 0341-326773| 0341-368883 Y Y ALL COVERAGE
1207 1327 RSIA. HUSADA BUNDA JL. PAHLAWAN TRIP NO. 2, ORO-ORO DOWO(0341) 569634; 566972;569799;
580169|0341-580169/569799 Y Y ALL COVERAGE
1208 2068 RS. LAWANG MEDIKA JL. DR CIPTO NO.8, KEL.BEDALI, KEC.LAWANG 0341-7057623/420888| -Y Y
ALL COVERAGE
1209 2048 RS. PRIMA HUSADA MALANGJL. BANJARARUM SELATAN NO. 3, MONDOROKO
SINGOSARI-MALANG0341-458679| 0341-441874 Y Y ALL COVERAGE
1210 2274 KLINIK & APOTEK KF 53 JL. KAWI NO.22 A MALANG 0341 362 301/ 364 056| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1211 2790 RSIA. GALERI CANDRA JL. BUNGA ANDONG NO.3 MALANG 65141 (0341) 478571| (0341) 478571 Y Y ALL COVERAGE
1212 2680 KIMIA FARMA 116 JL. LA SUCIPTO /148,MALANG 0341-489539| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1213 4089 RS. ISLAM GONDANGLEGI JL. HAYAM WURUK NO 66, GONDANGLEGI 0341 - 879047| - Y Y ALL COVERAGE
1214 0192 RS. BAPTIS BATU JL. RAYA TLEKUNG NO.1 JUNREJO, BATU0341-5941610341-598192/5|0341-
598192/50341-598911 Y Y ALL COVERAGE
1215 0125 RSIA. MELATI HUSADA JL. KAWI, NO.320341-325249 / 3570341 /
341357|0341-3413570341-365094/341357 Y Y ALL COVERAGE
1216 4740 MALANG EYE CENTER JL. DR. CIPTO NO. 3 (0341) 341666| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1217 3437 RSB. MARDI WALOEJA RAMPAL JL. WR. SUPRATMAN NO.01 MALANG (0341) 364756| - Y Y ALL COVERAGE
1218 2967 PERSADA HOSPITALJL. PANJI SUROSO ARAYA BUSINESS CENTER KAV.II-IV
MALANG0341-2996333| 0341-2993773 Y Y ALL COVERAGE
1219 4524 RS. PRASETYA HUSADAJL. RAYA NGIJO NO. 25 KARANGPLOSO KAB. MALANG
JAWA TIMUR(0341) 460558| (0341) 463404 Y Y ALL COVERAGE
1220 2171 APOTEK FARMARIN MALANG JL. W. R.SUPRATMAN C2 KAV.9 MALANG 0341-334163/4| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1221 0094 RSU. HERMINA TANGKUBANPRAHU MALANG JL. TANGKUBAN PRAHU, NO.33 MALANG
0341-325082 - 354844 -
354845/460341-354844/8|0341-
354844/8
0341-354843 Y Y ALL COVERAGE
1222 1561 RS. PERMATA BUNDA MALANG JL. SOEKARNO HATTA NO. 75, LOWOKWARU 0341-487487/407462| 0341-474242 Y Y ALL COVERAGE
1223 1978 RS. MUTIARA BUNDA MALANG JL. CIUJUNG NO 19, MALANG JAWA TIMUR (0341) 400403; 400722| - Y N ALL COVERAGE
1224 2789 RSIA. PURI MALANG JL. TAMAN SLAMET NO.20 MALANG 0341-325329| (0341) 342322 Y Y ALL COVERAGE
1225 4172 RSU UNIVERSITAS MUHAMMADIYAH MALANG JL. TLOGOMAS NO. 45 MALANG 0341 561666| 0341 561627 Y Y ALL COVERAGE
1226 3611 RSI. MADINAH KASEMBON JL. RAYA SUKOSARI NO. 32 KASEMBON MALANG 0354-326688/ 393000| 0354-328144 Y Y ALL COVERAGE
1227 3620 APOTIK KIMIA FARMA 77 JL. SUKARJO WIRYOPRANOTO 2K MALANG 0341-365298| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1228 0609 RS. PANTI NIRMALA JL. KEBALEN WETAN, NO.2-8 0341-362459| 0341-327930 Y Y ALL COVERAGE
MOJOKERTO
1229 0785 RS. EMMA JL. RAYA IJEN WATES NO.67 0321-396747|- 0321-334021 Y Y ALL COVERAGE
1230 1997 RS. ISLAM HASANAH MUHAMMADIYAHJL. HOS. COKROAMINOTO NO.26 - 28, MAGERS.
ARI,MOJOKERTO, JAWA TIMUR 613130321-321635| - Y Y ALL COVERAGE
1231 2818 RS. MUTIARA HATIJL. RAYA KEMANTREN WETAN 49, TERUSAN,GEDEG,
MOJOKERTO(0321) 7223400, 363442| - Y Y ALL COVERAGE
1232 1980 RS. SIDO WARASJL. RAYA PASAR SAWAHAN KM. 10 BANGSAL KAB.
MOJOKERTO0321-598621| 0321-598624 Y Y ALL COVERAGE
Page 27 of 40
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1233 0928 RS. GATOEL MOJOKERTO JL. RADEN WIJAYA NO.56 0321-321681,322329,399772-|- 0321-321684 Y Y ALL COVERAGE
1234 0088 RS. KARTINI MOJOKERTO JL. ERLANGGA, NO.137, MOJOSARI 0321-592261| 0321-595569 Y Y ALL COVERAGE
1235 0164 RS. REKSA WALUYA JL. MOJOPAHIT, NO.4220321-322170/3221710321-
322171/3937|0321-322171/39370321-322511 Y Y ALL COVERAGE
1236 3825 RSI. SAKINAH JL. RA BASUNI NO.12 MOJOKERTO 0321-321922| 0321-329670 Y Y ALL COVERAGE
NGAWI
1237 3872 RS. AT-TIN HUSADA JL. RAYA NGAWI-SOLO KM 4 0351747888| 351747666 Y Y ALL COVERAGE
PACITAN
1238 3770 PRODIA PACITAN JL. BASUKI RAHMAT NO. 14, PACITAN 63518 (0357) 884222| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PAMEKASAN
1239 3811 APOTEK KIMIA FARMA 274 JL. DIPONEGORO No 4, PAMEKASAN 0324611332| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1240 0113 RS. LARASATI JL. MANDILARAS, NO.74, PAMEKASAN 0324-328305| 0324-322080 Y Y ALL COVERAGE
PASURUAN
1241 3626 KIMIA FARMA 165 JL. WAHIDIN SUDIRO HUSODO NO 59 PASURUAN 0343-426342| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1242 1347 RS. MITRA SEHAT MEDIKA JL. BY PASS NO.6 PANDAAN 0343-636064| 0343-636083 Y Y ALL COVERAGE
PONOROGO
1243 0823 RSU. AISYIYAH PONOROGO JL. DR SUTOMO NO.18-24 0352-481784,461560,485093| 0352-484218 Y Y ALL COVERAGE
1244 3869 RS. DARMAYU PONOROGO JL. Dr. Soetomo No.44 - 50 0352-481320| 0352-461253 Y Y ALL COVERAGE
PROBOLINGGO
1245 1330 RSU. WONOLANGAN JL. RAYA DRINGU NO.118 0335-424007| 0335-431937 Y Y ALL COVERAGE
1246 0309 RS. DHARMA HUSADA JL. SOEKARNO HATTA NO.10 0335-422176| 0335-422698 Y N H&S,MAT
1247 4081 RS. RIZANIJL. RAYA SURABAYA SITUBONDO KM 135, KEL
SUMBEREJO, KEC PAITON0335 773444| - Y Y ALL COVERAGE
SIDOARJO
1248 1346 RS. CITRA MEDIKA SIDOARJO JL. RAYA SURABAYA, KM.44, KRAMAT TUMENGGUNG 0321-361000| 0321-361666/362956 Y Y ALL COVERAGE
1249 0249 RS. DELTA SURYA JL. PAHLAWAN NO.9031-8962531-8961271031-
8961271|031-8961271031-8961281/8944977 Y Y ALL COVERAGE
1250 0927 RS. ANWAR MEDIKAJL. DUSUN SEMAWUT, RT.10/RW.04, KEC. BALONGBENDO
/ JL. RAYA BY PASS KRIAN KM.33031-8972052, 8974943-|- 031-8988313 Y Y ALL COVERAGE
1251 1040 RS. MITRA KELUARGA WARU JL. RAYA LETJEN. S.PARMAN, NO.8 031-8543111/8542111-|- 031-8534333 Y Y ALL COVERAGE
1252 3614 PRODIA SIDOARJO JL. PAHLAWAN 12A SIDOARJO (031) 8961010| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1253 3839 APOTEK KIMIA FARMA 119 PERUM DELTASARI BLOK AN NO 11 0318556411| 318556411 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1254 3847 APOTEK KIMIA FARMA 261 JL. MAJAPAHIT NO.35 SIDOARJO 0318956674| 318956674 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1255 1336 KLINIK CITRA GADING MEDIKA JL. BRIGJEN KATAMSO BLOK A 408-409 REWIN WARU 031-8679727| 031-8683181 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1256 1339 KLINIK GRAHA MEDIKA JL. BRIGJEN KATAMSO NO.7 WARU 031 - 8554910| 031-8554911 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1257 3845 APOTEK KIMIA FARMA 180 JL. PAHLAWAN NO.10 SIDOARJO 0318947116| 318947116 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1258 1846 KLINIK MEDIS PUSURA SIDOARJO JL. RAYA CANDI NO. 49 SIDOARJO 031-8966345| 031-8075917 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1259 2273 KLINIK & APOTEK KF 124 JL. RAYA SEDATI GEDE NO. 59 SIDOARJO 031 866 7929| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1260 2755 RSU. BUNDA SIDOARJO JL. KUNDI NO.70 KEPUH KIRIMAN, WARU SIDOARJO (031) 8668880| (031) 8688218 Y Y ALL COVERAGE
1261 0271 RS. ISLAM SITI HAJAR SIDOARJO JL. RADEN PATAH NO.70 031-8921233/8961570| 031-8944438/8944990 Y Y ALL COVERAGE
1262 0545 RS.SITI KHODIJAH SIDOARJO JL. PAHLAWAN, NO.260, SEPANJANG
031-
7881130,7882123,7872081,6013437
3|
031-7876066 Y Y ALL COVERAGE
1263 1108 RSAB. SOERYA JL. RAYA KALIJATEN, NO.11-15, TAMAN SEPANJANG 031-7885011-|- 031-7873633 Y Y ALL COVERAGE
1264 3857 APOTEK KIMIA FARMA KAHURIPAN JL. KAHURIPAN NO.57 SIDOARJO 03151517736| 3151517736 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1265 4706 KLINIK IBU & ANAK PONDOK JATI PONDOK JATI AK 9-13 PAGERWOJO BUDURAN, SIDOARJO (031) 8052062| (031) 8052037 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1266 1342 KLINIK MEDIS GELORA PERUM TAMAN PINANG INDAH, BLOK B7, NO.3-3A 031-8929139| 031-8929123 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1267 3199 RSIA. KIRANA SIDOARJO JL. RAYA NGELOM 87 TAMAN - SIDOARJO 031-7881623| 031-7873010 Y Y ALL COVERAGE
SITUBONDO
1268 3096 RS. ELIZABETH PTP NUSANTARA XI JL. WR SUPRATMAN 2A SITUBONDO 0338-671174| 0338-678061 Y Y ALL COVERAGE
SURABAYA
1269 1362 RS. BHAKTI RAHAYU SURABAYA JL. KETINTANG MADYA I/16 031-8295922/8291799/8299217/23| 031-8293839 Y Y ALL COVERAGE
1270 1363 RS. BUNDA SURABAYA JL. RAYA KANDANGAN NO.23-24 BENOWO 031 - 7442220/7440077/7400694| 031 - 7442133 Y Y ALL COVERAGE
1271 1453 RS. ONKOLOGIARAYA GALAXI BUMI PERMAI BLOK A2/7 JL. ARIEF
RAHMAN HAKIM 182031-5914855| 031-5914860 Y Y ALL COVERAGE
1272 1454RSIA. PUTRI ( RS. KHUSUS OBSTETRI &
GINEKOLOGI )JL. ARIF RAHMAN HAKIM, NO.122 031-5999987| 031-5997215 Y Y ALL COVERAGE
1273 1201 RS. ADI HUSADA KAPASARI JL. KAPASARI NO.97-101 031-3764555| 031-3764666 Y Y ALL COVERAGE
1274 4446 RSIA KENDANGSARI MERR JL. DR. IR. H. SOEKARNO NO. 2, SURABAYA (031) 3814388| (031) 3813488 Y Y ALL COVERAGE
1275 3390 RSIA. LOMBOK DUA DUA ( JL. FLORES) JL. FLORES NO. 12 SURABAYA 031- 5022044| - Y Y ALL COVERAGE
1276 3613 PRODIA DARMO PERMAI JL. RAYA DARMO PERMAI SELATAN 1F, SURABAYA 60226 (031) 7328866| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1277 3831 APOTEK KIMIA FARMA 22 JL. BRATANG GEDE NO.100 A Surabaya 0315016713| 315016713 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 28 of 40
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1278 3832 APOTEK KIMIA FARMA 23 JL. KENDANGSARI BLOK J NO.7 0318414215| 318419345 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1279 3834 APOTEK KIMIA FARMA 25 JL. RAYA DARMO NO.2-4 0315677777| 315666454 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1280 3835 APOTEK KIMIA FARMA 26 JL. DIPONEGORO NO.94 0315677007| 315664420 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1281 3836 APOTEK KIMIA FARMA 45 JL. RAYA DARMO NO.94 0315676301| 315678819 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1282 3837 APOTEK KIMIA FARMA 52 JL. DUKUH KUPANG NO.54 0315671773| 315665755 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1283 3843 APOTEK KIMIA FARMA 166 JL. A.YANI 228 SURABAYA 0318291785| 318291785 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1284 3844 APOTEK KIMIA FARMA 175 JL. KARANG MENJANGAN NO.9 SURABAYA 0315991991| 315991991 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1285 3846 APOTEK KIMIA FARMA 243 JL. RAYA ARJUNO NO.151 SURABAYA 0315345031| 315459789 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1286 3165 LAB. PRODIA JEMURSARI JL. RAYA JEMURSARI NO.39, SURABAYA 031-8421010| 031-8438111 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1287 3848 APOTEK KIMIA FARMA 304 JL. PERAK TIMUR NO.166 SURABAYA 0313550007| 313550007 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1288 3850 APOTEK KIMIA FARMA 407 JL. MULYOSARI NO.288 SURABAYA 0315937994| 315937994 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1289 0829RS. PREMIER SURABAYA (RS. SURABAYA
INTERNASIONAL)JL. NGINDEN INTAN BARAT, BLOK B 031- 5993211|031-5993211 031- 5993214 Y Y ALL COVERAGE
1290 1690 RS. BEDAH SURABAYA JL. RAYA MANYAR NO 9 SURABAYA 031-5999369,5999339| 031-5995284 Y Y ALL COVERAGE
1291 1364 RS. ISLAM SURABAYA JEMURSARI JL. JEMURSARI NO.51-57 031 - 8471877/8471878/8471889| 031-8437784 Y Y ALL COVERAGE
1292 2272 APOTEK KIMIA FARMA 35 JL. NGAGEL JAYA SELATAN NO. 107 SURABAYA 60258 031 504 1276, 504 9098| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1293 2212 APOTEK FARMARIN SURABAYA JL. JEMUR ANDAYANI II/1 031-8418190| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1294 2217 RS. KENDANG SARI SURABAYA JL. RAYA KENDANGSARI NO.38 SURABAYA 031-8436200/8437200| 031-8494484 Y Y ALL COVERAGE
1295 2315 NATIONAL HOSPITAL SURABAYA BOULEVARD FAMILI SEL KAV 1 GRAHA FAMILI, SURABAYA 031-2975777| 031-297799 Y Y ALL COVERAGE
1296 2639 LAB. PRODIA SURABAYA JL. DIPONEGORO NO.107 SURABAYA 60241 031-28953900| 031-5675476 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1297 2476 RS. ROYAL SURABAYA JL. RUNGKUT INDUSTRI I/ 1 SURABAYA 031-8476111| 031-8476211 Y Y ALL COVERAGE
1298 2785 RS. ORTHOPEDI DAN TRAUMATOLOGY JL. EMERALD MANSION TX 10 CITRALAND, SURABAYA (031) 57431299| (031) 57431255 Y Y ALL COVERAGE
1299 2786 RS. PURA RAHARJA JL.PUNCANG ADI 12-14 (031) 5019898/ 5022151/ 5024591| - Y Y ALL COVERAGE
1300 0163 RS. DARMO JL. RAYA DARMO, NO.90 031 - 567 6253/54/55/56| 031-5620690 Y Y ALL COVERAGE
1301 0547 KLINIK MEDIS PUSURA 2 (RUNGKUT) JL. RUNGKUT ASRI TENGAH NO.2 031- 8705210| 031-8793028 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1302 0544 RS. ST.VINCENTIUS A.PAULO (RS. RKZ) JL. DIPONEGORO NO.51031-5677562,5687846,5663895031-
5687846|031-5687846031-5674748/5651057 Y Y ALL COVERAGE
1303 0895 RS. PHC SURABAYA JL. PRAPAT KURUNG SELATAN NO.1 TANJUNG PERAK 031-3294801/2/3|- 031-3294804 Y Y ALL COVERAGE
1304 0896 KLINIK KEBRAON JL. GRIYA KEBRAON BLOK FA NO.37 031-7663816-|- 031-7663816 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1305 0897 KLINIK BENOWO PONDOK BENOWO INDAH, BLOK PP/22 031-70547492-|- - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1306 0546 MEDIS PUSURA JL. KOM ( L) YOS SUDARSO, 9A031-5340604 / 031-
5471707/5328920|031-5327095 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1307 1000 RS. MUJI RAHAYU JL. RAYA MANUKAN WETAN 68 A, SURABAYA
031-
7404132/709837250000000|000000
0
- Y Y ALL COVERAGE
1308 0980 RS. ISLAM SURABAYA JL. JEND A YANI NO.2-4 031-8284505;8284506;8284507|- 031-8291805 Y Y ALL COVERAGE
1309 1548 KLINIK MEDIS PUSURA 5 (BALONGSARI) JL. BALONGSARI TAMA, BLOK B, NO.8-9 031-7416234| 031-7416234 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1310 2925 RS. MITRA KELUARGA KENJERAN JL. KENJERAN 506 SURABAYA 60114 (031) 99000880| (031) 99000885 Y Y ALL COVERAGE
1311 3851 APOTEK KIMIA FARMA 432 PANDUGO JL. PANDUGO MERR NO.2 SURABAYA 0318709962| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1312 3852 APOTEK KIMIA FARMA G-WALK RUKO TAMAN GAPURO B.2, G-WALK SURABAYA 0317411121| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1313 3855 APOTEK KIMIA FARMA CILIWUNG JL. CILIWUNG NO.76 SURABAYA 0315633156| 315633156 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1314 3856 APOTEK KIMIA FARMA KLAMPIS JL. KLAMPIS JAYA BLOK A NO.30 SURABAYA 0315926293| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1315 4082 RS. ISLAM DARUS SYIFA JL. RAYA BENOWO NO. 5 SURABAYA 0317406293| - Y Y ALL COVERAGE
1316 1365 RS. MATA UNDAAN JL. UNDAAN KULON, NO.19 031-5343806/531619| 031-5317503 Y Y ALL COVERAGE
1317 3769 PRODIA MEGA GALAXI (UNDAAN) SBYRUKO MEGA GALAXI, JL. KERTAJAYA INDAH TIMUR 14 C
NO. 6, SURABAYA 60282(031) 5991010| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1318 3197 RS. SURABAYA MEDICAL SERVICE JL. KAPUAS NO. 2 SURABAYA 031-5686161| - Y Y ALL COVERAGE
1319 4653 LAB KLINIK UTAMA BIOTEST SURABAYA JL KERTAJAYA INDAH F-304 SURABAYA 031-5929159/5929150| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1320 4128 LAB. PRODIA BOGOWONTO JL. BOGOWONTO NO. 14, SURABAYA ( PUSAT GMC ) 031-5631818| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1321 3002 LAB. KLINIK BIOTEST SURABAYA JL. RA. KARTINI NO.78, SURABAYA, JAWA TIMUR (031) 5678736| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1322 4209 RS. WIJAYA SURABAYA JL. MENGANTI 398 WIYUNG SURABAYA 031-7523087/031-7523282| Y Y ALL COVERAGE
1323 4231 RSIA NUR UMMI NUMBI (NUN) SURABAYA JL. MANUKAN TENGAH BLOK 51J/4-6 (031) 740 4391 ; 741 5313| - Y Y ALL COVERAGE
1324 0809 RS. SPESIALIS HUSADA UTAMA JL. PROF DR MOESTOPO 31-35031- 5017975/5018335(021)
9100682|(021) 9100682031-5010777 Y Y ALL COVERAGE
1325 3858 APOTEK KIMIA FARMA RUNGKUT JL. RUNGKUT MADYA NO.97 SURABAYA 0318721059| 318721059 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1326 3833 APOTEK KIMIA FARMA 24 JL. DHARMAWANGSA NO.24 0315032775| 315037664 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1327 3853 APOTEK KIMIA FARMA WIYUNG RUKO TPI BLOK A 17 RAYA MEGANTI SURABAYA 0317668267| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1328 1052RSIA. PUSURA TEGALSARI (MEDIS PUSURA
4)JL. TEGAL SARI NO.59 031-5473462-|- 031-5462033 Y Y ALL COVERAGE
1329 2001 RS. WIYUNG SEJAHTERA JL. KARANGAN PDAM NO.1-3 WIYUNG SURABAYA (031) 7532653| (031) 7533726 Y Y ALL COVERAGE
1330 5398 KLINIK KENCANA MEDIKA JL. RAYA KENDANGSARI NO. 78 SURABAYA (031) 8498880| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1331 0828 RS. AL. DR.RAMELAN SURABAYA JL. GEDUNG NO.1 SURABAYA (031) 8438153 / 031-8438154| (031) 8437511 Y Y ALL COVERAGE
1332 0548 KLINIK MEDIS PUSURA 3 (SUNGKONO) JL. MAYJEN, SUNGKONO, NO.64 031-5612120/22| 031-5668763 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1333 0830 RS. ADI HUSADA UNDAAN WETAN JL. UNDAAN WETAN NO40-44 SURABAYA031-5321256031-5318000|031-
5318000031- 5321081 Y Y ALL COVERAGE
1334 0136 RS. MITRA KELUARGA SURABAYA JL. SATELIT INDAH II, DARMO SATELIT 031-7345333| 031-7345955 Y Y ALL COVERAGE
1335 0081 SILOAM HOSPITALS SURABAYA JL. RAYA GUBENG NO. 70, SURABAYA 031-5031333/5031821| 031-5031533/5039313 Y Y ALL COVERAGE
TUBAN
1336 2002 RS. NAHDLATUL ULAMA TUBAN JL. LETDA SUCIPTO NO 211 TUBAN 0356-328244/(0356) 328299| (0356) 712072 Y Y ALL COVERAGE
1337 1198 RS. MEDIKA MULIA TUBAN JL. MOJOPAHIT, NO.699 TUBAN 0356-322744/324618| 0356-322666 Y Y ALL COVERAGE
TULUNG AGUNG
1338 0813 RS. ISLAM ORPEHA JL. KH. R. ABDUL FATAH 0355-323186| 0355-327691 Y Y ALL COVERAGE
1339 3708 APOTEK KIMIA FARMA 392 JL. I GUSTI NGURAH RAI NO. 10 TULUNGAGUNG 0355-322308| 0355-322308 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1340 3826 RS. ERA MEDIKAJL. RAYA PULOSARI, NGUNUT, TULUNGAGUNG, JAWA
TIMUR
0355-398706/396566/
08155199111|0355-398706 Y Y ALL COVERAGE
1341 3655 PRODIA TULUNGAGUNG JL. SUPRIADI NO.45 BLOK A.14, RUKO NIRWANA (0355) 336989| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KALIMANTAN BARAT
KETAPANG
1342 1800 RS. FATIMA KETAPANG JL. JEND SUDIRMAN NO. 27 KETAPANG 0534-32814| 0534-31649 Y Y ALL COVERAGE
PONTIANAK
1343 2729 RS. MITRA MEDIKA PONTIANAK JL. SULTAN ABDURRAHMAN NO.25, PONTIANAK, KALBAR (0561) 584888| - Y Y ALL COVERAGE
1344 2679KIMIA FARMA SERDAM (SUNGAI RAYA
DALAM)JL. SUNGAI RAYA DALAM RUKO B1 0561-737797| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1345 2253 KLINIK & APOTEK KF 32 PONTIANAK JL. TANJUNG PURA NO. 419 0561-731658| 0591-735802 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1346 2255 KIMIA FARMA 333 PONTIANAK JL. WAHID HASYIM NO.60 0561-768140| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1347 3574 PRODIA PONTIANAK JL. AHMAD YANI NO.6C PONTIANAK 0561-736177| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1348 1106 RS. SANTO ANTONIUS JL. KH. WAHID HASYIM NO.249 0561-732101-|- 0561-742242/733623 Y Y ALL COVERAGE
1349 1431 RSIA. ANUGERAH BUNDA KHATULISTIWA JL. AHMAD YANI NO. 5-7 0561-581818/085249922000| 0561-584100 Y Y ALL COVERAGE
1350 2254 APOTEK KIMIA FARMA 371 PONTIANAK JL. AHMAD YANI NO.5 0561-713988| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SANGGAU
1351 4108 RS. SENTRA MEDIKA SANGGAUJL. CEMPAKA KEL. ILIR KOTA RT.013/RW.OO3, KEC.
KAPUAS 78513(0564) 24240| (0564) 24248 Y Y ALL COVERAGE
SINGKAWANG
1352 2621 RSU. HARAPAN BERSAMA JL. N. P. BELITUNG NO. 61) SINGKAWANG 0562-631791| 0562-633359 Y Y ALL COVERAGE
1353 1368 RS. SANTO VINCENTIUS SINGKAWANG JL. P. DIPONEGORO NO.5 0562-631008| 0562-633881 Y Y ALL COVERAGE
KALIMANTAN SELATAN
BANJARBARU
1354 5424 CIPUTRA MITRA HOSPITAL JL. A. YANI KM. 7.8 BANJARMASIN, KALIMANTAN SELATAN 05116743999| - Y Y ALL COVERAGE
1355 2709 RSIA. LEMBAYUNG HUSADA JL. A. YANI KM 36 SIMPANG EMPAT (0511) 4777115| Y Y ALL COVERAGE
1356 4393 KLINIK & APOTEK KF 111 JL. JEND. A.YANI NO.10 RT.10/001 0511-6749027 / 4772141| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BANJARMASIN
1357 0849 RS. ISLAM BANJARMASIN JL. LET JEN S PARMAN GG.PURNAMA NO.1 BANJARMASIN0511-3350332, 3354896,
3350335|0511-3350332/350511-3351690 Y Y ALL COVERAGE
1358 1758 KLINIK SPESIALIS SARI MULIA JL. PANGERAN ANTASARI NO. 139 B 0511-3254341/3266960/3252570| 0511-3266960 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1359 2236 APOTEK KIMIA FARMA 217 JL.A.YANI KM 2 NO.136 0511-3252250/3251369| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1360 2237 KLINK & APOTEK KF 188 JL. LETJEN S. PARMAN NO. 42 0511-3354020| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1361 0631 RS. SARI MULIA JL. PANGERAN ANTASARI NO. 139B
0511 -
3274447/3261491/32525700511-
266960|0511-266960
0511 - 3257889 Y Y ALL COVERAGE
1362 3572 PRODIA BANJARMASINJL. JEND. ACHMAD YANI KM 3.5 NO. 131 - 133
BANJARMASIN 702350511-3273500| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1363 2235 KLINIK & APOTEK KF 61 JL. VETERAN NO. 51 0511-3250682/3252779| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1364 2677 KLINIK & APOTEK KF 265 JL. A.YANI 49, KUALA KAPUAS 0513-21406| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BATU LICIN
1365 2471 KLINIK MEDIKA BATULICINJL.RAYA BATULICIN - SERONGGO KM.1 SEI KECIL, TANAH
BUMBU0518-71570| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KANDANGAN
1366 1799 RS. PAHLAWAN MEDIKA CENTERJL. PAHLAWAN NO. 15 KANDANGAN KAB. HULU SUNGAI
SELATAN0517-23191| 0517-23678 Y Y ALL COVERAGE
Page 30 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
MARTAPURA
1367 2721 RS. PELITA INSANIJL. SEKUMPUL NO.66 MARTAPURA 70614, KALIMANTAN
SELATAN(0511) 4722210, 4722220| (0511) 4722230 Y Y ALL COVERAGE
1368 1797 RSIA. MUTIARA BUNDA MARTAPURA JL. TAISIR NO. 2, MARTAPURA O511- 4721901| 0511- 4720664 Y Y ALL COVERAGE
1369 4392 KLINIK & APOTEK KF 179 JL. JEND. A YANI KM.39.5 NO.47 0511-4722654| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TABALONG
1370 2707 RS. PERTAMINA TANJUNGJL. GAS, KOMPERTA MURUNG PUDAK TANJUNG,
KALIMANTAN SELATAN 71571(0526) 2022550/2023068| (0526) 2027678 Y Y ALL COVERAGE
TANAH BUMBU
1371 3996 KLINIK SIMPANG TANAH BUMBU
JL. GAWE SABUMI RT 08 NO. 083, DESA BERSU. JUD,KEC.
SIMPANG EMPAT, KAB. TANAH BUMBU, KALIMANTAN
SELATAN 72200
(081258339911 / 081953230699)| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1372 1011 KLINIK SURYA MEDIKA SATUI (SMS) JL. PROPINSI NO 11, RT 17 SUNGAI DANAU SATUI 0512-61717|0778-322122 0512-61312 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KALIMANTAN TENGAH
MUARA TEWEH
1373 2675 KLINIK & APOTEK KF 156 JL. Y.SINSENG NO.1 M.TEWEH, KALTENG 0519-21698| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PALANGKARAYA
1374 2889RS. ISLAM PKU MUHAMMADIYAH
PALANGKARAYAJL. RTA MILONO KM .2,5 MENTENG, JEKAN RAYA 0536-3244801-4803| 0536-3239444 Y Y ALL COVERAGE
1375 2673 KLINIK & APOTEK KF 112 JL. DIPONEGORO 8, P.RAYA 0536 -3221952| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1376 3764 PRODIA PALANGKARAYA JL. DIPONEGORO NO. 20 A-B, PALANGKARAYA (0536) 3235399| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PANGKALAN BUN
1377 3529 KLINIK KESUMAJL. ISKANDAR NO. 12 A, PANGKALAN BUN, KALIMANTAN
TENGAH(0532) 23935| (0532) 23935 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SAMPIT
1378 2672 KLINIK & APOTEK KF 103 JL. H.M ARS. YAD, NO.120, SAMPIT 0531-24828| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1379 4085 KLINIK SARI MEDIKA SAMPIT JL. P.ANATASARI NO 5 SAMPIT 0531-25288; 0531-24396| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KALIMANTAN TIMUR
BALIKPAPAN
1380 1374SILOAM HOSPITALS BALIKPAPAN (RS
BALIKPAPAN HUSADA)
JL. MT.HARYONO NO.9 RINGROAD, BALIKPAPAN -
KALIMANTAN TIMUR0542 - 8862 999| 0542-7206517 Y Y ALL COVERAGE
1381 2634 KLINIK & APOTEK KF 425 SEPINGGAN JL. MARS. MA ISWAHYUDI NO. 72 0542 7210391| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1382 0633 RS. PERTAMINA BALIKPAPAN JL. JEND SUDIRMAN NO.1 0542-7517485/734020/21| 0542-7517493 Y Y ALL COVERAGE
1383 3573 PRODIA BALIKPAPANKOMP. PERTOKOAN BANDAR KLANDASAN BLOK D-11, JL.
JEND. SUDIRMAN, BALIKPAPAN 761130542-739337| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1384 0632 RS. RESTU IBU JL. JEND. A. YANI, NO.120542-427342/3/40542-427342|0542-
4273420542-441494/417290 Y Y ALL COVERAGE
1385 1520 APOTEK KIMIA FARMA 56 JL. A.YANI, NO.95 0542-412244, 424187,7031852| 0542-731560 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1386 3459 SUMATERA EYE CENTRE BALIKPAPANRUKO SENTRA EROPA BLOK AA 2B NO.16 BALIKPAPAN
BARU(0542) 876732/876941| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1387 0686 PANACEA CLINICKOMP MAL FANTASI BLOK AB2 NO.18-20 BALIKPAPAN
BARU 76114
0542-877898,72040460751-
444712/5|0751-444712/50542-877641/7031819 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1388 0692 APOTIK KANIDA FARMA II JL. JEND. SUDIRMAN, NO. 2390542-424309,0542 420496|0542-
4204960542-424031 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1389 1457 KLINIK & APOTEK KF 136 BALIKPAPAN JL. MT. HARYONO NO. 72 0542-763962| 0542-761629 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1390 0672 RSIA. PERMATA HATI BALIKPAPAN JL. IMAM BONJOL NO.1 0542-413932/413928| 0542 - 413928 Y Y ALL COVERAGE
1391 2073 KLINIK MEDIKA UTAMA ( KMU SETIARA )JL. MULAWARMAN NO. 24 RT 7 MANGGAR BARU
BALIKPAPAN, KALIMANTAN TIMUR0542-770846| 0542-770847 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1392 2632 KLINIK & APOTEK KF 293 JL. A. YANI NO.45 KARANG JATI 0542 792420| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1393 2633 KLINIK & APOTEK KF 68 JL. JEND.SUDIRMAN NO.2-3 PERTOKOAN KLANDASAN 0542 422691| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1394 2635 KLINIK & APOTEK KF 329 JL. SOEKARNO HATTA KM 5 / 86, BPN 0542 860024| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1395 1213 RS. BALIKPAPAN BARU KOMP. BALIKPAPAN BARU JL. MT.HARYONO BLOK. A-A3 0542-877330| 0542-877331 Y Y ALL COVERAGE
BATU KAJANG
1396 1767 KUSUMA MEDICAL CENTER BATUKAJANG JL. NEGARA KM.141 RT 09C PASER 0543-5230262| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
BONTANG
1397 3874 KLINIK SATELIT 3 RS. PKT BONTANG JL. LETJEN S PARMAN NO. 5 BONTANG 0548-23388| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1398 2474 KLINIK RS. PKT 1 JL. IMAM BONJOL BONTANG-KALTIM 0548-24800| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1399 2118 RS. AMALIA BONTANGJL. R. SOEPRAPTO NO. 22 BONTANG BARU, KOTA
BONTANG KALTIM0548-25050| 0548-23275 Y Y ALL COVERAGE
1400 1214 RS. PUPUK KALTIM BONTANG JL. OKSIGEN NO.1, KOMP.PUPUK KALTIM 0548-41118/41444| 0548-41555 Y Y ALL COVERAGE
1401 3189 RSI. BONTANG ( YABIS ) JL. BRIGJEN KATAMSO NO. 40 BONTANG 0548 - 20003| 0548-22644 Y Y ALL COVERAGE
KUTAI KARTANEGARA
1402 1074 KLINIK MAJU SEJAHTERA JL. MOH. HATTA, HANDIL 3, MUARA JAWA 0541-691891/ 081333001836-|- 0541-691892 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1403 3707 KLINIK QICAJL. RA. KARTINI RT. 21, DESA GAS ALAM MUARA BADAK,
KUTAI KARTANEGARA082227276911| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PASER
1404 5520 KLINIK ATHIRAHJL. NEGARA KM. 140 NO. 09 RT. 009 KEC BATU SOPANG
KAB PASER KALTIM081257436633 / 081255578967| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 31 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
SAMARINDA
1405 0230 RS. H. DARJAD JL. DAHLIA, NO.4 0541-732698,734123,732609| 0541-732562 Y Y ALL COVERAGE
1406 0636 RS. DIRGAHAYU JL. GN. MERB. ABU, NO. 620541-742161/748309/7483100541-
748309/10/11|0541-748309/10/110541-748308/744636 Y Y ALL COVERAGE
1407 2631 KLINIK & APOTEK KF 114 SAMARINDA JL. P.HIDAYATULLAH NO.63, SAMARINDA 0541 742198| 0541 742198 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1408 3575 PRODIA SAMARINDAJL. A. YANI KOMP. CENDRAWASIH TRADE CENTER BLOK A-
6, SAMARINDA(0541) 736198| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1409 3460 SUMATERA EYE CENTRE SAMARINDA JL. A. YANI NO. 6 A-B SAMARINDA (0541) 200257, 200258| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1410 1794 RSIA. THAHA BAKRIE JL. PANGERAN HIDAYATULLAH NO 11 SAMARINDA 0541-742191| 0541-200075 Y Y ALL COVERAGE
1411 3813 KLINIK & APOTEK KF 385 (PPO) JL. P.M.I NO.25 SAMARINDA 0541-734334| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1412 4795 KLINIK SILOAM SAMARINDAJL. A. YANI (PEMUDA II) NO.3, RT. 10 - KEL. TEMINDUNG
PERMAI KEC. SUNGAI PINANG, SAMARINDA(0541) 2090 900| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1413 2453 RS. SAMARINDA MEDIKA CITRA JL. KADRIE OENING NO.81 RT.35 SAMARINDA 75124 (0541) 7273000| (0541) 7272888 Y Y ALL COVERAGE
1414 2473 RS. SIAGA RAMANIAJL. RAMANIA 3 ( JL. JEND. SOEPARTO) SAMARINDA,
KALTIM0541-739772| 0541-749131 Y Y ALL COVERAGE
1415 2105 KLINIK & APOTEK KF 138 KARTIKA JL. KH AGUS SALIM NO. 30 SAMARINDA 75121 0541-737447| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1416 2104 KLINIK & APOTEK KF 105 JL. DR. SUTOMO NO 36-37 SAMARINDA 0541-741639| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1417 1656 KLINIK MELATI HUSADAJL. CIPTO MANGUN KUSUMO RT 12 NO 52 KEL
SENGKOTEK LOA JUAN SAMARINDA0541-260721| 0541-241752 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SANGATTA
1418 1801 RS. SOHC JL. YOS SUDARSO IV, NO. 1, TELUK LINGGA 0549-23417| 0549-23417 Y Y ALL COVERAGE
1419 1376RS. PKT PRIMA SANGATTA (RS. PUPUK
KALTIM )
JL. YOS SUDARSO I NO.1 SANGATTA - KALIMANTAN
TIMUR0549-24555| 0549-24524; 25927 Y Y ALL COVERAGE
1420 1556 RS. MELOY SANGATTA JL. YOS SUDARS. O II NO.101 SANGATTA - KALIMANTAN TIMUR 0549-2026258| 0549-24222 Y Y H&S,MAT
KALIMANTAN UTARA
BULUNGAN
1421 4681 KLINIK BUNYU MEDIKAJL. EMPLASMEN RT. 07 DESA BUNYU TIMUR, KAB.
BULUNGAN(0511) 2055374| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TARAKAN
1422 1529 RS. PERTAMINA TARAKAN JL. MULAWARMAN NO. 14, TARAKAN 0551-31403/31665| 0551-33310 Y Y ALL COVERAGE
1423 1972 RUMKITAL ILYAS TARAKAN JL. MARTADINATA NO 29 0551-24320 / 21353| - Y Y ALL COVERAGE
LAMPUNG
BANDAR LAMPUNG
1424 5605 RSIA BELLEZA KEDATON JL.SULTAN HAJI LABUHAN RATU 0721-773333| 0721-773338 Y Y ALL COVERAGE
1425 1092 RS. MITRA HUSADA PRINGSEWU JL. JEND A. YANI NO.14 PRINGSEWU, LAMPUNG 0729-23792-|- 0729-23836 Y Y ALL COVERAGE
1426 1228 RS. BUMI WARAS JL. WOLTER MONGINSIDI, NO.2350721-
254589/261122/257925/267855|0721-257926 Y Y ALL COVERAGE
1427 1692 RS. HARAPAN BUNDA LAMPUNGJL. RAYA LINTAS SUMATERA NO.30 SEPUTIH JAYA
LAMPUNG TENGAH0725-26766| 0725-25091 Y Y ALL COVERAGE
1428 1693 RSIA. MUTIARA PUTRI JL. HOS COKROAMINOTO NO 76 ENGGAL LAMPUNG 0721-252579/254999| 0721-254282 Y Y ALL COVERAGE
1429 0486 RS. IMMANUEL WAY HALIM JL. SOEKARNO-HATTA, WAY HALIM 0721-704900,704630/628| 0721-704807/784897 Y Y ALL COVERAGE
1430 1970 RSIA. BUNDA ASY-SYIFAJL. DR.SUSILO NO. 54 PAHOMAN TELUK BETUNG UTARA
BANDAR LAMPUNG0721-259259/256256| 0721-266800 Y Y ALL COVERAGE
1431 1871 RS. PERTAMINA BINTANG AMIN JL. PRAMUKA NO 27, LAMPUNG 0721-273601| 0721-273597 Y Y ALL COVERAGE
1432 1378 RS. URIP SUMOHARJO JL. URIP SUMOHARJO NO.200 SUKARAME 0721-771322/23/24| 0721-771321/707990 Y Y ALL COVERAGE
1433 0487 RS. ADVENT LAMPUNG JL. TEUKU UMAR, NO.48 KEDATON BANDAR LAMPUNG 0721-703459| 0721-786349/770717 Y Y ALL COVERAGE
1434 1632 RS. NATAR MEDIKA (YADIKA GROUP)JL. RAYA NATAR NO. 04 MUARA PUTIH, KEC NATAR
LAMPUNG SELATAN0721-92521/92519| 0721-92519 Y Y ALL COVERAGE
1435 2110 KLINIK & APOTEK KF 131 BANDAR LAMPUNG JL. KARTINI NO. 44-45 BANDAR LAMPUNG 0721240291| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1436 2112 KLINIK & APOTEK KF 327 BANDAR LAMPUNG JL. JEND. SUDIRMAN NO. 88 BANDAR LAMPUNG 0721- 5600608| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1437 2176 RSIA. RESTU BUNDAJL. K.H. HASYIM ASHARI NO. 73, TELUK BETUNG SELATAN -
BANDAR LAMPUNG0721-484158/484185| 0721-482832 Y Y ALL COVERAGE
1438 2465 RSIA. PURI BETIK HATIJL. PAJAJARAN NO.109, JAGABAYA, BANDAR LAMPUNG,
LAMPUNG0721-787799| - Y Y ALL COVERAGE
1439 2767 RS. ISLAM ASY-SYIFAA
JL. NEGARA LINTAS SUMATERA KM.65 YUKUM JAYA -
BANDAR JAYA, KEC. TERB. ANGGI BESAR, LAMPUNG
TENGAH 34162
(0725) 25264| (0752) 527476 Y Y ALL COVERAGE
1440 1352 RS. GRAHA HUSADA LAMPUNGJL. GAJAH MADA, NO. 6 GH, TANJUNG AGUNG, BANDAR
LAMPUNG0721-240000| 0721-263181/268417 Y Y ALL COVERAGE
1441 4394 KLINIK & APOTEK KF 222 JL. GAJAH MADA NO.58B BANDAR LAMPUNG 0721 5601300| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1442 2901 LAB. PRODIA PAHOMAN LAMPUNG JL. JEND. SUDIRMAN NO. 120 PAHOMAN LAMPUNG 0721-8017700/1| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1443 5124 LAB. PRODIA TELUK BETUNG Jl. Ikan Hiu Teluk Betung 085768958661| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
LAMPUNG SELATAN
1444 4523 KLINIK LEMATANG MEDICAL CENTERJL. IR. SUTAMI NO. 153, DESA LEMATANG, KEC. TANJUNG
BINTANG, KAB. LAMPUNG SELATAN 35361(0721) 350145; 0823 0607 2345| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1445 3170 KLINIK DUA PUTRI JAYAJL. IR. SUTAMI KM.30 DESA MALANG SARI, TANJUNG
SARI-LAMPUNNG SELATAN085366797190| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
METRO
1446 4516 PRODIA METRO JL. JEND SUDIRMAN NO. 37 LAMPUNG 0725-7855205| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
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29-Mar-17
TANJUNG HARAPAN
1447 2921 RSU. HANDAYANIJL. N. SOEKARNO - HATTA NO : 94, TANJUNG HARAPAN,
KOTABUMI, LAMPUNG UTARA0724328399| Y Y ALL COVERAGE
MALUKU
AMBON
1448 2911 RS. T TK.II DR.J.A. LATUMETEN JL. DR. TAMAELA N0. 2 AMBON 0911-353555| 0911-354763 Y Y ALL COVERAGE
1449 2265APOTEK KIMIA FARMA PEL.26
AMBON,MALUKU
JL. DR. KAYADOE, KEL. KUDAMATI, AMBON-MALUKU(DI
DALAM RS. HALAUSSY)0911-351677| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1450 1439 RS. BHAKTI RAHAYU AMBON JL. BATU KERB. AU, BELAKANG RRI 0911-342746| - Y Y ALL COVERAGE
1451 2264 LAB. PRODIA AMBON JL. ANTHONY RHEBOK NO: 1 B-C 0911-314296| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1452 2912 RS. SUMBER HIDUP JL. ANTHONY RHEBOK, HONIPOPU, SIRIMAU, AMBON, MALUKU (0911) 352373, 351654| 0911-352401 Y N H&S,MAT
MALUKU UTARA
TERNATE
1453 2259 LAB. KLINIK PRODIA TERNATE JL. A. MONONUTU NO:21 TERNATE, MALUKU UTARA 0921-3111246| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1454 2260 KLINIK & APOTEK KF 168 TAKOMA TERNATE JL. HASAN ESA 151 TERNATE, MALUKU UTARA 0921-3121037/3123076| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1455 2012 RS. ISLAM TERNATE JL. PEMUDA NO. 131 KEL.TOBELEU 0921-3121623| - Y N ALL COVERAGE
1456 1503 RS. MEDIKA HARIFALM JL. ZAINAL ABIDINSYAH, NO.25, KOMPLEX POHON PALA 0921-3126087| 0921-3126198 Y N H&S,MAT
NAD
ACEH
1457 4836 RS. PERTAMEDIKA UMMI ROSNATIJL. SEKOLAH MO. 5 GAMPONG ATEUK PAHLAAWN KEC.
BAITURRAHMAN KOTA BANDA ACEH(0651) 35092| - Y Y ALL COVERAGE
BANDA ACEH
1458 3958 KLINIK & APOTEK KF 397 SIGLI JL. PERDAGANGAN NO.1 SIGLI - ACEH 065321536 / 085265313030| 65321536 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1459 2962 LAB. PRODIA BANDA ACEHJL. T.H.M. DAUD BEUREUH NO. 45 B-C, BANDA ACEH
23126(0651) 23823, 637807| (0651) 22387 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1460 2187 APOTEK KIMIA FARMA 402 LAMPRIET JL. TEUKU DAUD BEUREUEH NO. 167-171 0651-637008| 0651-635 669 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1461 2186 APOTEK KIMIA FARMA ACEH (37) JL. DIPONOGORO NO 8 0651-21559| 0651-635 669 N YGP,SP,OP,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1462 1789 KLINIK SPECIALIS CEMPAKA LIMA JL. TENGKU M. DAUD BEUREUEH NO 156 0651-33345 / 08126922264| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1463 1100 RS. TEUNGKU FAKINAH JL. JEND. SUDIRMAN NO.27-29 0651-41454 / 081377028888-|- 0651-47646/49454 Y N H&S,MAT
1464 1790 RS. CEMPAKA AZ ZAHRA JL. POCUT BAREN NO 36-38-40 BANDA ACEH 0651-31066| 0651-25281 Y N ALL COVERAGE
1465 4816 RS. MEUTIA JL. CUT MEUTIA NO. 55 KP. BARU, BANDA ACEH (0651) 33149| Y Y ALL COVERAGE
BIREUN
1466 1694 RS. TELAGA BUNDA BIERUN JL. PEUTUA BANTA NO 7, GP BIERUN 0644-324433| 0644-324433 Y Y ALL COVERAGE
LANGSA
1467 2711 RS. CUT MEUTIA JL. GARUDA NO. 1 KEL. KEBON BARU LANGSA ACEH (0641) 425314| (0641) 426285 Y Y ALL COVERAGE
1468 2667 KLINIK & APOTEK KF 81 JL. TM.ZEIN NO.1E ,LANGSA,ACEHTIMUR 0641-21020| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
LHOKSEUMAWE
1469 2903 LAB. PRODIA LHOKSEUMAWE JL. MERDEKA NO. 18 LHOKSEUMAWE ( DEPAN TELKOM ) 0645-47205| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1470 1892 RS. SAKINAH LHOKSEUMAWE JL. ANTARA NO 30, LHOKSEUMAWE 0645-45534/42158| - Y N H&S,MAT
1471 1975 KLINIK VINCA ROSEAJL. DARUSSALAM NO. 36 KP JAWA BARU, KOTA
LHOKSEUMAWE - ACEH UTARA
0645-7011117 / 46725/
085338437373|0645-630218 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1472 2119 KLINIK & APOTEK KF 60 JL. MERDEKA NO. 47 B -C LHOKSEUMAWE BANDA ACEH 0645-41152| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
MEULABOH
1473 3686 RS. SWASTA MONTELLAJL. BERINGIN JAYA SAMPING MESJID AGUNG, MEULABOH,
ACEH BARAT(0655) 7551974; 085277358711| - Y Y ALL COVERAGE
1474 4212 KLINIK CEMPAKA LIMA MEULABOH JL. SWADAYA NO 39 F/39 G MEULABOH082361103699/08116822077/08126
980242|N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PIDIE
1475 4106 KLINIK MUTIARA SIGLIJL. PROF A. MADJID IBRAHIM NO. 10, SIGLI, PIDIE, ACEH
241510653-21529| 0653-24565 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
NTB
BIMA
1476 3453 LAB. PRODIA BIMA JL. SOEKARNO HATTA NO. 39 D BIMA 0374-646910| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1477 3506 KIMIA FARMA NO. 263 BIMA JL. SOEKARNO - HATTA NO. 3 BIMA 0374-42910| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
LOMBOK TIMUR
1478 1894 RS. ISLAM NAMIRA SELONG JL. KH AHMAD DAHLAN NO 7. KEC SELONG KOTA SELONG 0376-22693/21004/| - Y Y ALL COVERAGE
1479 3503 KIMIA FARMA NO. 55 SELONG JL. M. YAMIN NO. 77 SELONG - LOMBOK TIMUR -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
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MATARAM
1480 3452 LAB. PRODIA MATARAM JL. PEJANGGIK NO. 107 MATARAM 0370-635248; 635010| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1481 4688 KLINIK PRATAMA ASY-SYIFA JL. PANJI TILAR NEGARA NO. 136 MATARAM -| -N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1482 3504KIMIA FARMA NO. 231 MATARAM (Group KF
189)JL. SALEH SUNGKAR NO. 33 AMPENAN -| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1483 3507KIMIA FARMA 458 CATUR WARGA (Group KF
189)JL. CATUR WARGA NO. 17 MATARAM -| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1484 3505KIMIA FARMA NO. 234 MATARAM (Group KF
189)JL. SELAPARANG NO. 53 MATARAM -| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1485 4358 RS. GRHA ULTIMA MEDIKA JL. MAJAPAHIT NO. 10, MATARAM (0370) 623999; 628111| - Y Y ALL COVERAGE
1486 1957 RSIA. PERMATA HATI MATARAM JL. MAJAPAHIT NO 10 0370-631999| 0370-632999 Y Y ALL COVERAGE
1487 1956 RSI. SITI HAJAR MATARAM JL. CATUR WARGA NO. 6 MATARAM 0370-623498| - Y Y ALL COVERAGE
1488 2258 KLINIK & APOTEK KF NO. 189 JL. SRIWIJAYA NO. 295 MATARAM 0370-633211| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1489 1645 RS. HARAPAN KELUARGA MATARAMJL. AHMAD YANI NO. 9 SELAGALAS, SANDUBAYA,
MATARAM - LOMBOK (NTB)0370-670000,6177027,6177000| 0370-673666 Y Y ALL COVERAGE
1490 1124 RSB. EXONERO JL. PEMUDA NO.16, DASAN AGUNG 0370-636454,644440| 0370-647023/636454 Y Y ALL COVERAGE
1491 1539 RS. RISA SENTRA MEDIKA JL. PEJANGGIK, NO.115, CAKRANEGARA 0370-632117/625560/| 0370-625559 Y Y ALL COVERAGE
1492 1827 RS. BIOMEDIKA JL. BUNG KARNO NO 143 MATARAM 0370-645137| 0370-645138 Y Y ALL COVERAGE
SUMBAWA
1493 3482 KIMIA FARMA NO. 303 SUMBAWA JL. CENDRAWASIH SUMBAWA BESAR 0371 - 24029| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
NTT
ENDE
1494 3500 KIMIA FARMA KELIMUTU ENDE JALAN KELIMUTU ENDE (0381)-2627456| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KUPANG
1495 4099 RSIA. LEONA JL. SOEVARDI NO. 20 OEBUFU, KUPANG 0380-840212| 0380-840212 Y Y ALL COVERAGE
1496 2972 RS. KARTINI KUPANGJL. FRANS SEDA NO.17,KELURAHAN TUAK DAUN MERAH,
KUPANG-852280380-80265111/0380 - 831 270| (0380) 831270 Y Y ALL COVERAGE
1497 3464 RS. WIRASAKTI JL. MOH. HATTA KUPANG (0380)-821131 / 0380-824735| - Y Y ALL COVERAGE
1498 2240 RS. ST CAROLUS BORROMEUS JL. HR. KOROH KM. 08 BELLO KUPANG 0380 - 8030530, 085100030530| - Y Y ALL COVERAGE
1499 3494 LAB. PRODIA KUPANG JL. CAKDOKO NO. 52 KUPANG (0380)-824566, 821010, 8080020| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1500 1380 KLINIK & APOTIK KARTINI JL. ELTARI I NO.2 0380-833010| 0380-820660 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1501 1647 RSIA. DEDARI JL. RANTAI DAMAI 69 D TDM OEBUFU KUPANG-NTT 0380-8553914/826774| 0380-830041/8553914 Y Y ALL COVERAGE
1502 2242 KLINIK & APOTEK KF 135 KUPANG JL. M. HATTA 46 0380- 830944/820541/831296| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1503 2245 KLINIK & APOTEK KF 101 KUPANG JL. HEREWILA NO. 38 KUPANG 0380- 827270| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1504 2666 KLINIK & APOTEK KF LALAMENTIK JL. WJ.LALAMENTIK,95 D-E, KUPANG 0380-840362| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1505 3975 SILOAM HOSPITALS KUPANG JL. RW MONGINSIDI RT. 014 RW. 004 FATUTULI 0380-8530900/8530911| 0380-8530933 Y Y ALL COVERAGE
LABUHAN BAJO
1506 4762 SILOAM HOSPITALS LABUAN BAJOJL. GABRIEL GAMPUR RT.013. RW.005, DUSUN V, KEC.
KOMODO, KAB. MANGGARAI BARAT, LABUHAN BAJO(0385) 238 1900 EXT. 22001| (0385) 238 1911 EXT. Y Y ALL COVERAGE
SIKKA
1507 3616 LAB. KLINIK PRODIA MAUMEREJL. EL TARI, KEL. MADAWAT, KEC. ALOK, MAUMERE
FLORES(0382) 21146| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PAPUA
JAYAPURA
1508 2188 KLINIK & APOTEK KF 172 JAYAPURA JL. AHMAD YANI NO. 67,JAYAPURA 0967-534921/533 322| 0967-534921 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1509 1469 RS. DIAN HARAPANJL. TARUNA BHAKTI KEL YABANSAI DISTRIK HERANG -
JAYAPURA
0967-573479/ 572325; 0852 4400
4655;0813 44100 432|0967-573362/573979 Y Y ALL COVERAGE
1510 4203 LAB. KLINIK CITO JL. ARGAPURA NO. 11 E, JAYAPURA 0967-522080 / 085244202002| 0967-522082 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
MERAUKE
1511 4213 LAB. KLINIK CITO MERAUKE JL. RAYA MANDALA 293, MERAUKE PAPUA 0971-325367| 0971-325368 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TIMIKA
1512 2716 RS. KASIH HERLINA JL. A. YANI NO. 37 TIMIKA PAPUA 99910(0901) 321433/321443 /
082398124027|(0901) 324310 Y Y ALL COVERAGE
1513 2732 KLINIK PURI HUSADA JL. BUDI UTOMO UJUNG, TIMIKA PAPUA (0901) 3126661/081240760444| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PAPUA BARAT
SORONG
1514 1475 RS. PERTAMINA SORONG JL. AHMAD YANI NO. 13 0951-321362, 321581| 0951-326110 Y Y ALL COVERAGE
RIAU
DUMAI
1515 4169 KLINIK CITRA MEDIKA JL. M. YAMIN SH NO. 58, DUMAI (0765) 38508; 4300044| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1516 2766 KLINIK IGA DUMAI JL. SUTAN SYARIF KASIM NO.221, DUMAI - RIAU 0765-4397481/ 085264881796| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1517 1621KLINIK RAWAT INAP & BERSALIN PADU
SERASIJL. JEND. SUDIRMAN NO. 188 DUMAI, RIAU 0765-438189 / 438289| 0765-438008 Y Y ALL COVERAGE
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29-Mar-17
DURI
1518 0922 KLINIK THURSINA JL. JEND SUDIRMAN NO.65 SIMPANG PADANG 0765-595573|0765-595573 0765-595573 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1519 0921 RS. PERMATA HATI DURI JL. JEND SUDIRMAN NO.37 SIMPANG PADANG0765-94902/95799, GIGI913670765-
0765-596899|0765-0765-5968990765-595799 Y Y ALL COVERAGE
1520 0930 RSU. THURSINA JL. HANGTUAH NO.93 0765-597782 / 595573|0765-595573 0765-597773 Y Y ALL COVERAGE
1521 0624 RSIA. MUTIA SARI JL. BATHIN BETUAH, NO.1-A, SIMPANG PADANG 0765-93635/92080| 0765-597972/55979 Y Y ALL COVERAGE
1522 4121 LAB. PRODIA DURI JL. HANG TUAH 105 D, DURI 0765-93008| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
INDRAGIRI HILIR
1523 2302 RS. INDRAGIRI JL. TRIMAS NO. 77 TEMBILAHAN INDRAGIRI HILIR - RIAU 0768-23555| 0768-21539 Y Y ALL COVERAGE
PANGKALAN KERINCI
1524 1369 RS. EFARINA PANGKALAN KERINCIJL. LINTAS TIMUR NO 1, PANGKALAN KERINCI, KAB
PELALAWAN0761-494500/493980| 0761- 493981 Y Y ALL COVERAGE
PEKANBARU
1525 3568 PRODIA PEKANBARU JL. CEMPAKA NO. 80 B-C, PEKANBARU, RIAU 28156 0761-45542| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1526 1535 EKA HOSPITAL PEKANBARU JL. SOEKARNO HATTA, KM.6,5 0761-6989999| 0761-6989944 Y Y ALL COVERAGE
1527 3003 PRAKTEK DRG. TENSY A. T JL. AHMAD YANI 111C ( APOTEK PANGEAN ) PEKANBARU 081365910510 ; 081364223894| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1528 0663 RSIA. ERIA BUNDA JL. KH. AHMAD DAHLAN, NO.163 0761-23100/23600| 0761-47235 Y Y ALL COVERAGE
1529 2837KLINIK MATA SUMATERA EYE CENTER
PEKANBARUJL. ARIFIN AHMAD NO. 58 PEKANBARU 0761-565686| 0761-565786 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1530 2926 RSIA. ANDINI JL. TUANKU TAMBUSAI NO.55, PEKANBARU (0761) 33612| (0761) 33649 Y Y ALL COVERAGE
1531 5205 RS. MATA PEKANBARU EYE CENTERJL. SOEKARNO HATTA NO.236 KEL.SIDOMULYO TIMUR,
KEC MARPOYAN DAMAI07617875191-92| 0761-7875195 Y Y ALL COVERAGE
1532 4739 AULIA HOSPITAL PEKANBARU JL. HR.SUBRANTAS No. 63, PANAM 0761-6700 000| (0761) 854815 Y Y ALL COVERAGE
1533 0664 RS. ISLAM IBNU SINA PEKANBARU JL. MELATI, NO.60 0761-24242/26011| 0761-35698 Y Y ALL COVERAGE
1534 0841 RSIA. ZAINAB JL. RONGGOWARSITO I NO.1 0761-24000| 0761-859448 Y Y ALL COVERAGE
1535 0920 RS. AWAL BROS PEKANBARU JL. JEND SUDIRMAN NO.117 0761-47333-|- 0761-47222 Y Y ALL COVERAGE
1536 2101 APOTEK KIMIA FARMA 229 JL. SUDIRMAN 724 0761 29186| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1537 2102 KLINIK & APOTEK KF 93 JL. JEND. SUDIRMAN NO 175 0761-32796| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1538 1596 RS. KHUSUS BEDAH & KEBIDANAN SYAFIRA JL. JEND.SUDIRMAN NO.134 PEKANBARU 0761-856517,35360| 0761-41887 Y Y ALL COVERAGE
1539 2409 RSIA. BUDHI MULIA JL.SOEKARNO HATTA NO.226-228 ARENGKA, PEKANBARU 0761-3069900/8417200| 0761-8417255 Y Y ALL COVERAGE
1540 2590 RSB. ANNISA TANGKERANGJL. GARUDA NO. 66 TASKURUN UNJUNG TANGKERANG
TENGAH, PEKANBARU(0761) 848 652| (0761) 848 652 Y Y ALL COVERAGE
1541 2468 RS. AWAL BROS PANAMJL. HR. SOEBRANTAS RT. 01/RW. 03 NO 88 KEL. TUAH
KARYA KEC. TAMPAN PANAM, PEKANBARU0761-586 888| 0761 586111 Y Y ALL COVERAGE
1542 4511 RS. A. YANI PEKANBARU JL. JEND. A. YANI NO. 73, PEKANBARU (0761) 856370| - Y Y ALL COVERAGE
1543 4689 PRODIA PEKANBARU(PHC) JL. JENDRAL SUDIRMAN NO. 203 L-M PEKANBARU (0761) 8403383, 856739| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1544 4853 RS. PRIMA PEKANBARUJL. BIMA NO. 1 NANGKA UJUNG, KEL. DELIMA KEC.
TAMPAN, PEKANBARU, RIAU(0761) 8419007| (0761) 8419006 Y Y ALL COVERAGE
ROKAN HILIR
1545 4136 KLINIK UTAMA CAHAYA JL. LINTAS RIAU UJUNG TANJUNG KAB. ROKAN HILIR 081-266818300| - Y Y ALL COVERAGE
1546 2199 KLINIK AGUNG JL. JEND. SUDIRMAN KM. 8, BAGAN BATU 0765-552459| 0765-552459 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
ROKAN HULU
1547 1878 RS. AWAL BROS UJUNG BATUJL. JEND. SUDIRMAN NO. 314 UJUNG BATU ROKAN HULU
RIAU0762-7363329| 0762-7363334 Y Y ALL COVERAGE
RIAU KEPULAUAN
BATAM
1548 2482 KLINIK & APOTEK KF 269 JL. JEND SUDIRMAN, BATAM CENTRE, BATAM 0778 461482; 363375| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1549 2480 KLINIK & APOTEK KF 128KOMP. PERTOKOAN WIJAYA BLOK A NO. 4 SEI HARAPAN -
BATAM0778 323697| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1550 4150 KLINIK & APOTEK KF NO. 230 PANBIL MALL BLOK A NO. 5 0778-371149| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1551 1010 RS. ST. ELISABETH - BATAM JL. ANGGREK BLOK II, BALOI 0778 - 457357-|- 0778-457710/422473 Y Y ALL COVERAGE
1552 0485 GENTA MEDICAL CENTER MUKA KUNING INDAH, BLOK F, NO.10 0778-361909| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1553 0484 RB. BUDI ROSARI JL. MAHKOTA SIMPANG, NO.1, BENGKONG MAHKOTA 0778-427854| 0778-432833 Y Y ALL COVERAGE
1554 0584 RS. AWAL BROS BATAM JL. GAJAH MADA KAV.1 BALOI 0778 - 431777| 0778-430777 Y Y ALL COVERAGE
1555 0582 RS. BUDI KEMULIAAN BATAM JL. BUDI KEMULIAAN, NO.1 0778-426865, 454044|0778-454044 0778-454055 Y Y ALL COVERAGE
1556 3608 PRODIA BATAMJL. ENGKU PUTRI, KOMPLEKS MAHKOTA RAYA BLOK E NO.
12A-12B, BATAM CENTRE - BATAM 29432(0778) 7495735| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1557 4336 KLINIK DUNIA MEDICAL CENTRERUKO PERUMNAS FANINDO BLOK B NO. 7-10, BATAM
29432, KEP. RIAU(0778) 7432 899| (0778) 3581209 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1558 4838 RSIA. FRISDHY ANGELJL. RADEN PATAH BLOK B NO. 1-3, LUBUK BAJA, BALOI,
BATAM0778-424 901/ 425134| Y Y ALL COVERAGE
1559 2486 KLINIK & APOTEK KF 137 KOMP.SAGULUNG MAS INDAH B3, BATAM 0778 392146| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1560 2487 KLINIK & APOTEK KF 224 KOMP MUKA KUNING INDAH II B2.3, BATAM 0778 363375| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 35 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1561 2448 YAHYA MEDICAL CENTER & APOTIK ZAHRUNIKOMPLEK RUKO SAGULUNG PERMAI BLOK B14-15,
SAGULUNG KOTA, BATAM(0778) 392748| (0778) 392749 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1562 2479 KLINIK & APOTEK KF 413 KOMP. RUKO BOTANIA GARDEN BLOK A 1 NO. 1 C - BATAM 0778 7431199| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1563 2503 RS. GRAHA HERMINE KOMP. RUKO ASIH RAYA NO.9-15, BATU AJI (0778) 363318, 363127| (0778) 363164 Y Y ALL COVERAGE
BINTAN
1564 1240 RB. & BP TIARA MEDIKAJL. KAMPUNG HARAPAN RT 01/01 TELUK SASAH, TANJUNG
UBAN0771-484427| 0771-484427 Y Y ALL COVERAGE
1565 1241 KLINIK BERSALIN ERNES JL. PERMAISURI NO.8 TANJUNG UBAN 0771-483212| 0771-482738 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
BINTAN UTARA
1566 2457 RSUD. TANJUNG UBANJL. INDUN SURI SIMPANG BUSUNG NO.1 TANJUNG UBAN
29152(0771) 482655/ 082324421982| - Y Y ALL COVERAGE
KARIMUN
1567 1291 APOTIK DEVI FARMA JL. AHMAD YANI, SEI PASIR, MERAL, TANJUNG BALAI 0777-21388| 0777-368974/21388 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1568 1271 RS. BAKTI TIMAH KARIMUNJL. CANGGAI PUTRI TELUK UMA KABUPATEN KARIMUN
PROVINSI KEPULAUAN RIAU 296610777-7367085| 0777-7333251 Y Y ALL COVERAGE
1569 1208 MEDIC CENTRE CLINICJL. AHMAD YANI, KOMPLEK KARIMUN INDAH, BLOK B,
NO.1, TANJUNG BALAI0777- 325 561| 0777- 325561 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1570 0874 RSB. GRAHA RAP JL. R.USMAN, BATU LIPAI, TANJUNG BALAI 0777-326097| 0777-323857 Y YH&S,GP,SP,OP,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1571 1237 KLINIK SAYANG IBUJL. AHMAD YANI, NO.20, BARAN SATU, MERAL, TANJUNG
BALAI0777- 216 76| 0777- 222 52 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
TANJUNG PINANG
1572 4416 KLINIK & APOTEK KF 169JL. BRIGJEND. KATAMSO, TG.PINANG(JL. RAJA ALI HAJI
KM 4 NO. 3)0771 - 317631| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1573 4397 KLINIK & APOTEK KF 297 JL. BANTAR CETEK KM.9 TANJUNG PINANG 0771 441619| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1574 4396 KLINIK & APOTEK KF 109 JL. MT.HARYONO KM.3,5 TANJUNG PINANG 0771 313590| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1575 3766 PRODIA TANJUNG PINANG JL. IR. SUTAMI, RUKO VILLA AKASIA NO. 20 (0771) 25305| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1576 2483 KLINIK & APOTEK KF 31 JL. BINTAN 656-658,TG.PINANG 0771 22879, 21091| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SULAWESI BARAT
MAMUJU
1577 4087 RSUD. MAMUJU JL. RE. MARTADINATA MAMUJU - SULBAR 0426-21107| - Y Y ALL COVERAGE
1578 4521 PRODIA MAMUJU JL. ABD WAHAB AZASI NO. 43 MAMUJU 081513905286| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SULAWESI SELATAN
BONE
1579 4819 RS. HAPSAH JL. URIP SUMOHARJO, NO. X BONE 92731 (0481) 2911811| - Y Y ALL COVERAGE
LUWU TIMUR
1580 5607 RS. INCO SOROWAKOJL. DIPONEGORO NO. 1 SOROWAKO, NUHA, LUWU TIMUR,
SULAWESI SELATAN
021-5249100 ext 9612 /
08114053016|021-5249585 Y Y ALL COVERAGE
MAKASSAR
1581 5237 CEREBELLUM CLINIC JL. SWADAYA NO. 4, MAKASSAR (0411) 427184| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1582 4985RSU. WISATA UNIVERSITAS INDONESIA
TIMURJL. ABDUL KADIR NO. 70, MAKASSAR, 90224 (0411) 888444, 888666| (0411) 8115656 Y Y ALL COVERAGE
1583 5593 RS. HERMINA MAKASSARJL. TODDOPULI RAYA TIMYUR LORONG MAKASSAR
BORONG KEC. MANGGALA(0411) 4091817| (0411) 4091775 Y Y ALL COVERAGE
1584 5145 PRODIA-BATU PUTIH JL. G. BATU PUTIH NO. 25, MAKASSAR -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1585 4163 KLINIK & APOTEK KF MAROS JL. POROS MAROS MACCOPA 0411-372020|- - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1586 1388 RATULANGI MEDICAL CENTRE JL. SAM RATULANGI NO.28 0411-878605/06/88| 0411-878587 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1587 1389 RS. GRESTELINA JL. LETJEN HERTASNING RAYA NO.51 0411-448855/448852| 0411-448854 Y Y ALL COVERAGE
1588 1390 RS. IBNU SINA YBW-UMI JL. URIP SUMOHARJO, KM.5, NO.264 0411-452958/5781595/452917| 0411-425397 Y Y ALL COVERAGE
1589 1393 RSIA. SITI KHADIJAH 1 MAKASSAR JL. KARTINI NO.15-17 MAKASSAR 0411-3624554/8614661| 0411-3627119 Y Y ALL COVERAGE
1590 0641 RS. STELLA MARIS MAKASSAR JL. SOMBA OPU NO.273, PO.BOX 122 0411-871391/873346| 0411 - 859545 Y Y ALL COVERAGE
1591 4415KLINIK & APOTEK IMEDICAL SPECIALIST
CENTREJL. RACING CENTRE NO. 17 MAKASSAR (0411) 4668835| (0411) 4668834 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1592 4817KLINIK TELKOMEDIKA MAKASSAR (THC
MAKASSAR)Jl. DR. RATULANGI NO. 126 MAKASSAR 0411 8122283 / 081355551600| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1593 1630 RS. AWAL BROS MAKASSAR JL. JEND. URIP SUMOHARJO NO.43 MAKASSAR 0411-454567/455558| 0411-455123 Y Y ALL COVERAGE
1594 1190 RS. AKADEMIS JAURY YUSUF PUTERA JL. JEND. M YUSUF NO. 47A, PATTUNUANG, MAKASSAR
0411-
3617343/3613054/3613071/3617344
|
0411-313914 Y Y ALL COVERAGE
1595 2291 KLINIK & APOTEK KF 199 ERLINA JL. URIP SUMOHARJO NO. 32 MAKASSAR 0411 449 936| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1596 2657 KLINIK & APOTEK KF HERTASNING JL. HERTASNING NO 11 - MAKASSAR 0411- 442945| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1597 2658 KLINIK & APOTEK KF 33 JL. AHMAD YANI, NO.17 - 19, MAKASSAR 0411-3616722| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1598 2659 KLINIK & APOTEK KF PETTARANI JL. PETTARANI 18, MAKASSAR 0411-857210 / 857215| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1599 2660 KLINIK & APOTEK KF DAENG TATA JL. DAENG TATA 69, MAKASSAR 0411-880685| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1600 2661 KLINIK & APOTEK KF 250 JL. DR.RATULANGI 59, MAKASSAR 0411- 582895| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1601 2717 KLINIK & APOTEK KF 38 JL. HASANUDDIN, NO.46, MAKASSAR 0411- 3617110| - N YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-
RG,RM-KM,RM-RB,PHAR
1602 2904 LAB. PRODIA MAKASSAR JALAN SUNGAI SADDANG NO.40 MAKASSAR (0411) 872727/446666| (0411) 873110 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 36 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1603 2905 LAB. PRODIA MAKASSAR JL. BOULEVARD
JL. BOULEVARD RUKO RUBY I NO. 7-8, PANAKKUKANG
MAS, MAKASSAR 90222 (PUSAT GMC - PPS
PANAKKUKANG)
(0411) 446666| (0411) 457000 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1604 4161 KLINIK & APOTEK KF GOWA JL. SULTAN HASANUDDIN NO. 8 GOWA 0411-869842|- - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1605 1847 SILOAM HOSPITALS MAKASSARJL. METRO TANJUNG BUNGA KAV. 9 PANAMBUNGAN KEC.
MARISSO - MAKASAR
0411-
3662900/8117555/8117430/5290000
|
0411-8117911 Y Y ALL COVERAGE
1606 3085 RS. UNIVERSITAS HASANUDDIN JL. PERINTIS KEMERDEKAAN KM.11 MAKASSAR 90245 0411 - 591331| - Y Y ALL COVERAGE
1607 3065 RSB. SENTOSA MAKASSAR JL. JEND. SUDIRMAN 52, 0411-3612720| (0411) 3619711 Y Y ALL COVERAGE
1608 5129 PARAHITA DIAGNOSTIC CENTER JL. GUNUNG LATIMOJONG NO.123 0411-3623573| N Y ALL COVERAGE
1609 2178 APOTEK FARMARIN MAKASSARJL. LANDAK LAMA NO 27, KEL LABUANG BAJI KEC
MAMAJANG0411-870397| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1610 5414 RSIA. PERMATA HATI MAKASSAR JL. TAMALANREA RAYA POROS BTP BLOK 10M NO.9-10 0411-4774085 / 582278| Y Y ALL COVERAGE
PALOPO
1611 3772 LAB. PRODIA PALOPO JL. ANDI DJEMMA NO. 53, PALOPO 91921 (0471) 327467| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1612 0914 RS. AT MEDIKA JL. ANDI JEMMA, NO.09 0471-21596-|- 0471-23008 Y Y ALL COVERAGE
PARE PARE
1613 3773 LAB. PRODIA PARE PARE JL. ANDI MAPPATOLA NO. 7, PARE-PARE 91114 (0421) 22265 / 7007433| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1614 1394 RS. FATIMA PARE-PARE JL. ILHAMV KOTAK POS 12 0421-21847| 0421-21328 Y Y ALL COVERAGE
SENGKANG
1615 4129 LAB. PRODIA SENGKANG JL. AP PETTARANI NO.18, SENGKANG 0485-323409| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SULAWESI TENGAH
PALU
1616 2287 APOTEK KIMIA FARMA 449 TATURA JL. WOLTER MONGINSIDI NO. 145 PALU, SULTENG 0451-429832| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1617 0639 RSU. WOODWARD (BALA KESELAMATAN) JL. LH. WOODWARD NO.1 0451 - 421769, 423744| 0451 - 423744 Y Y ALL COVERAGE
1618 3577 PRODIA PALU JL. S. PARMAN NO. 16, PALU 94111 0451-451639| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1619 2288 KLINIK & APOTEK KF 390 PALU JL. SETIABUDI NO. 65 D PALU SULTENG 0451-425132| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SULAWESI TENGGARA
BAU BAU
1620 4761 SILOAM HOSPITALS BUTONJL. SULTAN HASANUDDIN No. 58, KEL.BATULO,
KEC.WOLIO KOTA BAUBAU, SULAWESI TENGGARA0402-2825555| (0402) 2823020 Y Y ALL COVERAGE
1621 2300 RS. MURHUMJL. SULTAN MURHUM NO. 69 KEL. WAJO KEC. MURHUM
SULTENG, BAU BAU0402-2822650| 0402-2823919 Y Y ALL COVERAGE
KENDARI
1622 2286 KLINIK & APOTEK KF 288 JL. A. YANI NO. 84 KENDARI 0401 319 6186| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1623 1537 RS. ST. ANNA JL. DR. MOH.HATTA, NO.65A 0401-3123092| 0401-3124872 Y Y ALL COVERAGE
1624 3576 PRODIA KENDARI JL. SAOSAO NO. 207 KENDARI 0401-3121789| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1625 2285 KLINIK & APOTEK KF 104 JL. MOH. HATTA NO. 77 KENDARI 93124 0401 3127182| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SULAWESI UTARA
KOTAMOBAGU
1626 3762 PRODIA KOTAMOBAGU JL. D.I. PANJAITAN NO. 13, KOTAMOBAGU 95176 (0434) 2629104| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
MANADO
1627 4244 KLINIK & APOTEK KF 290 MANADO JL. MARTHADINATA RAYA NO. 38 0431 861878| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1628 1502 RS. ADVENT MANADO JL. 14 FEBRUARI, NO.1, TELING ATAS 0431-847950/858429| 0431-850012 Y Y ALL COVERAGE
1629 1798 SILOAM HOSPITALS MANADO JL. SAM RATULANGI NO 22 MANADO 0431-7290900| 0431-8883133 Y Y ALL COVERAGE
1630 2875 POLIKLINIK PERTAMINA MANADO JL. SAM RATULANGI N0.8 MANADO -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1631 2805 RSIA. KASIH IBU MANADOKOMPLEKS BAHU MALL BLOCK. C NO. 23) JL. N. WOLTER
MONGINSIDI NO. 10431 834780/834667| 0431 834721 Y Y ALL COVERAGE
1632 2230 KLINIK & APOTEK KF NO. 74 JL. SAM RATULANGI NO.31 MANADO 93117 0431-864012| 0431-850838 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1633 2232 KLINIK & APOTEK KF WENANG 309JL. LIMIMUNT NO. 12 A KEL. TIKALA KUMARAKA, KEC.
WENANG, MANADO0431-867163/840087| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1634 2233 LAB. PRODIA MANADO JL. SAM RATULANGI NO. 72 MANADO 95111 0431-874567| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1635 2231 APOTEK KIMIA FARMA MALALAYANG KP. REL NO. 5 RS. VP MALALAYANG 0431-838278| 0431-838277 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1636 2656 KLINIK & APOTEK KF 129 JL. A.YANI, SARIO, MANADO 0431- 861571| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1637 2650 KLINIK & APOTEK KF 331, BAHU JL. W.MONGINSIDI 29 A,MANADO 0431-842786| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1638 2654 KLINIK & APOTEK KF 332 JL. SAM RATULANGI NO.338,, WANEA 0431- 843002| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1639 5427 RS. MANADO MEDICAL CENTER JL. RAJAWALI NO.8, PAAL 2 0431-866641 / 082190285345| 0431-866641 Y Y ALL COVERAGE
1640 4245 KLINIK & APOTEK KF TUMINTING MANADO JL. HASANUDIN NO 137 MANADO 0431 855420| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SUMATERA BARAT
BUKIT TINGGI
1641 1398 RSU. MADINA JL. GURU HAMZAH NO.17 0752-21388 EXT 228| 0752-626677 Y Y ALL COVERAGE
1642 3602 PRODIA BUKIT TINGGI JL. A. RIVAI 23, BUKIT TINGGI 26116 (0752) 23348| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 37 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1643 2114 KLINIK & APOTEK KF 146 BUKIT TINGGI JL. JEND. SUDIRMAN NO 14 BUKIT TINGGI -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PADANG
1644 2060 KLINIK & APOTEK KF 94 PADANG JL. PROKLAMASI N. 24 PADANG 0751-891195| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1645 2113 KLINIK & APOTEK KF 238 PADANG JL. PATIMURA NO 18 PADANG 0751-23620| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1646 0304 RS. SELAGURI JL. A.YANI, NO.26 0751 -33010/21953| 0751-840051 Y Y ALL COVERAGE
1647 4840 RSB. MUTIARA BUNDA JL. S. PARMAN NO. 142 PADANG, SUMATERA BARAT 0751-7054076| - Y Y ALL COVERAGE
1648 1569 RSIA. CICIK JL. DR. SUTOMO NO.94 MARAPALAM PADANG 25125 (0751) 38846; 38866| (0751) 841286 Y Y ALL COVERAGE
1649 4794 RS. NAILI DBSJL. RATULANGI NO. 24 RT. 001 RW. 008, KEL. KAMPUNG
JAO, KEC. PADANG BARAT(0751) 8951900 ; 8951901| (0751) 8951902 Y Y ALL COVERAGE
1650 4195 RS. KHUSUS BEDAH ROPANASURI JL. ALUR NO.8 PADANG 0751-31938,33854| 0751-25735 Y Y ALL COVERAGE
1651 4051 RSIA. SITI HAWA JL. PARAK GADANG RAYA NO.35 0751-841251| - Y Y ALL COVERAGE
1652 3569 PRODIA PADANG (JL. PATTIMURA) JL. PATTIMURA NO. 3 A, PADANG 25113 0751-38795| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1653 4805 ZIRCONIC DENTAL CLINIC JL. H. AGUS SALIM NO. 57 B PADANG (0751) 841917; (0811666310)| -N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1654 2714 SEMEN PADANG HOSPITALJL. BY PASS KM 7 KEL. PISANG, KEC. PAUH PADANG -
SUMBAR(0751) 777888, 4782999., 4782997| (0751) 4782990 Y Y ALL COVERAGE
1655 2369 RS. MATA PADANG EYE CENTER (PEC) JL. PEMUDA NO. 53 PADANG - SUMBAR 0751-30094| 0751-30098 Y Y ALL COVERAGE
1656 1320 RSI. SITI RAHMAH PADANG JL. RAYA BY PASS KM 15 AIE PACAH, PADANG 0751-463059| 0751-463531 Y Y ALL COVERAGE
1657 0423 RSU. BUNDA MEDICAL CENTER (RSU. C-BMC) JL. PROKLAMASI NO.31-33-37 PADANG 0751-23164/29536/21151/24750| 0751-23200 Y Y ALL COVERAGE
1658 0616 RS. YOS SUDARSO JL. SITUJUH, NO.1 0751-33230/33231| 0751-31811 Y Y ALL COVERAGE
PAYAKUMBUH
1659 2115 KLINIK & APOTEK KF 372 PAYAKUMBUH JL. JEND. SUDIRMAN PAYAKUMBUH -| KF_ N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1660 1720 RSI. IBNU SINA PAYAKUMBUH JL. PEMUDA NO 14 PAYAKUMBUH 0752-92222/90555| 0752-796744 Y Y ALL COVERAGE
TEBING TINGGI
1661 3787 LAB. PRODIA TEBING TINGGI JL. SUDIRMAN NO. 257 D, TEBING TINGGI 26014 (0621) 22494| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SUMATERA SELATAN
BATU RAJA
1662 1284 RS. SANTO ANTONIO JL. KOMISARIS UMAR NO. 33, BATURAJA 0735-320395/322418/324700| 0735-320201 Y Y ALL COVERAGE
LUBUK LINGGAU
1663 1869 KLINIK SEKATAJL. YOS SUDARS. O NO. 230 TABAH JEMEKEH, LUBUK
LINGGAU0733-321357| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1664 2715 RS. AR BUNDA LUBUK LINGGAUJL. GARUDA NO 245 RT 03 KEL. BANDUNG KIRI, KEC.
LINGGAU BARAT 1(0733) 324955/324963| (0733) 321892 Y Y ALL COVERAGE
MUARA ENIM
1665 4372 RS. BUKIT ASAMJL. Raya Bukit Asam No 118, Tanjung Enim Sumatera
Selatan0734-451096| - Y Y ALL COVERAGE
PALEMBANG
1666 1884 SILOAM SRIWIJAYA PALEMBANGJL. POM IX KEL. LOROK PAKJO KEC. ILIR BARAT 1
PALEMBANG0711-5229100| 0711-5649100 Y Y ALL COVERAGE
1667 3965 RS. SRIWIJAYA EYE CENTERJL. JEND.SUDIRMAN KM. 4,5 NO.502 KEL. 20 ILIR, KEC. IT
I(0711) 5611976/419680| Y Y ALL COVERAGE
1668 1622 RS. HERMINA PALEMBANGJL. BASUKI RAHMAT NO.897 RT.011/003 KEL.20 ILIR II
KEC.KEMUNING0711-352525| 0711-366945 Y Y ALL COVERAGE
1669 0883 RS. BUNDA PALEMBANG JL. DEMANG LEBAR DAUN, PALEMBANG0711-312866,3118660711-
311866|0711-3118660711-355553 Y Y ALL COVERAGE
1670 0688 RS. ISLAM SITI KHADIJAH PALEMBANG JL. DEMANG LEBAR DAUN, LORONG PAKJO 0711-356008| 0711-311884 Y Y ALL COVERAGE
1671 0627 RS. PUSRI JL. MAYOR ZEN, KOMPLEK PUSRI NO. 1 0711 -712222-712111| 0711-712071 Y Y ALL COVERAGE
1672 4034 RSIA. SITI MIRZAJL. DEMANG LEBAR DAUN RT 035 RW 010, KELURAHAN
DEMANG LEBAR DAUN, KECAMATAN ILIR BARAT I0711-446272| 0711-441345 Y Y ALL COVERAGE
1673 4132 LAB. PRODIA VETERAN JL. VETERAN 930/C2, 9 ILIR, PALEMBANG 0711-377239/362487| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1674 2839 POLIKLINIK PERTAMINA PALEMBANG JL. JEND. AHMAD YANI NO. 1247. 1 PALEMBANG -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1675 2787 RS. PERTAMINA PLAJU PERTAMEDIKAJL. PENGANTINGAN NO.1 KOMPLEK PERTAMINA PLAJU
SUMATERA SELATAN 30268(0711) 597401/597442| (0711) 542388 Y Y ALL COVERAGE
1676 2185 KLINIK & APOTEK KF 209 JL. LETKOL ISKANDAR NO. 222 0711354717/0711362245| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1677 2442 LAB. PRODIA PALEMBANG JL. BASUKI RAHMAT NO.801 PALEMBANG 30113 0711-411304| 0711-5610294 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1678 2423 RSIA. AZZAHRAJL. BRIGJEN HASAN KASIM NO.1-2 BUKIT SANGKAL
PALEMBANG0711-822723| 0711-826044 Y Y ALL COVERAGE
1679 2394 KIMIA FARMA 239 JL. MP. MANGKUNEGARA 0711 - 823503| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1680 0817 RS. RK. CHARITAS JL. JEND. SUDIRMAN NO.10540711-350426/3533750711-
353374/5|0711-353374/50711-362205/377088 Y Y ALL COVERAGE
1681 0803 RS. MYRIA JL. KOL. H. BURLIAN KM. 7 NO 228 PALEMBANG 0711-411610/412433/421914| 0711-414052 Y Y ALL COVERAGE
1682 0885 RSIA. YK. MADIRA JL. JEND SUDIRMAN NO.1051 C-D PALEMBANG0711-364954,362766, 374802,
3747850711-356173|0711-356173(0711) 356173 Y Y ALL COVERAGE
PENUKAL ABAB LEMATANG ILIR
1683 2152 RSUD. TALANG UBIJL. TAMAN SISWA KELURAHAN PASAR BHAYANGKARA
,KEC TALANG UBI, KAB PENUKAL ABAB LEMATANG ILIR0713-390487/0713-390566-391111| 0713-391456/390487 Y Y ALL COVERAGE
PRABUMULIH
1684 0824 RS. PERTAMINA PRABUMULIHJL. KESEHATAN, NO.100, KOMPLEK PERTAMINA
PRABUMULIH
0713-
383333/382749/322069/382742/382
731(0713) 382731|(0713) 382731
0713-321903/325181 Y Y ALL COVERAGE
1685 3953 RS. FADHILAHJL. JENDRAL SUDIRMAN NO. 01 PATIH GALUNG
PRABUMULIH(0713) 3300032| (0713) 3300032 Y Y ALL COVERAGE
1686 1449 RS. AR BUNDA PRABUMULIH JL. ANGKATAN 45, KEL GUNUNG IBUL PRABUMULIH TIMUR 0713-322954, 7003330| 0713-325980/322954 Y Y ALL COVERAGE
SUMATERA UTARA
ASAHAN
1687 2351 RS. SETIO HUSODOJL. S. M. RAJA N0 67 KISARAN, ASAHAN SUMATERA
UTARA0623-44999| 0623-43394 Y Y ALL COVERAGE
Page 38 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
BINJAI
1688 1652 RS. LATERSIA JL. SOEKARNO HATTA, KM.18 NO.451, BINJAI 061-8829588/8829788| 061-8822565 Y Y ALL COVERAGE
1689 2776 RSU. SYLVANI JL. N.PERINTIS KEMERDEKAAN.NO. 21 BINJAI (061) 80045925| (061) 80045923 Y Y ALL COVERAGE
1690 1624 RSU. ARTHA MEDICA JL. SAMANHUDI NO. 22 BINJAI 061-8820387/8828167| 061-8830757 Y Y ALL COVERAGE
1691 3722 PRODIA BINJAI JL. SUDIRMAN NO. 25, BINJAI 20714 (061) 8828269| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1692 1811 RS. BIDADARI BINJAIPERINTIS KEMERDEKAAN NO 174 A KEBUN LADA KOTA
BIJAI061- 8830003| 061 - 8826004 Y Y ALL COVERAGE
BRASTAGI
1693 1542 RS. EFARINA ETAHAM BRASTAGI JL. JAMIN GINTING, NO.1, DESA RAYA, 0628-323716/17| 0628-213718 Y Y ALL COVERAGE
DELI SERDANG
1694 4359 RS. THEOTOKOSJL.BESAR NAMORAMBE NO. 10 -15, KEC. NAMORAMBE
DESA DELI TUA MEDAN 20355(061) 7032854; 7032694;| (061) 7032806 Y Y ALL COVERAGE
1695 2348 RS. PATAR ASIH LUBUK PAKAMJL. BAKARAN BATU DESA TEMPATAN KEC. BERINGIN, NO.
45 KAB. DELI SERDANG061-7950449,50| 061-7950313 Y Y ALL COVERAGE
KARO
1696 4118 LAB. PRODIA KABANJAHE JL. VETERAN NO. 21 ( RSU ESTER ) KABANJAHE, KARO 0628-323321| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
KISARAN
1697 3730 PRODIA KISARAN JL. IMAM BONJOL NO. 177, KISARAN 21222 (0623) 348599| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
LANGKAT
1698 1653 RS. PERTAMINA PANGKALAN BRANDANJL. WAHIDIN NO.01 PANGKALAN BRANDAN LANGKAT-
SUMUT0620-322612,322455| 0620-323392 Y Y ALL COVERAGE
LUBUK PAKAM
1699 2023 RS. GRAND MEDISTRA LUBUK PAKAM JL. RAYA MEDAN-LUBUK PAKAM KM 25 NO. 66 061-7955114| 061-7950114 Y Y ALL COVERAGE
1700 4119 LAB. PRODIA LUBUK PAKAM JL. AHMAD DAHLAN NO. 69, LUBUK PAKAM 061-7952030| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
MEDAN
1701 0925 RS. ST ELISABETH - MEDAN JL. H. MISBAH NO.7, MEDAN 061-4144737/4522010/4144240| 061 - 4143168 Y Y ALL COVERAGE
1702 0742 RSU. MARTHA FRISKA JL. KOL. YOS SUDARS. O KM.6, NO.91, PULO BRAYAN 061-6610910| 061-6612005 Y Y ALL COVERAGE
1703 1193 RSU. SARAH JL. BAJA RAYA NO. 10 PETISAH 061-4528044| 061-4529454 Y Y ALL COVERAGE
1704 1061 RS. ESTOMIHI JL. SISINGAMANGARAJA NO.235 MEDAN061-7861771,7864656061-
7864656|061-7864656061-7866660 Y Y ALL COVERAGE
1705 0741 RS. ISLAM MALAHAYATI JL. DIPENOGORO NO.2-4, MEDAN 061 - 4518766| 061-4519474 Y Y ALL COVERAGE
1706 0740 RS. HERNA JL. MAJAPAHIT NO.118A, MEDAN061 -451 0766|IBU HENI/DR
LIMENTA061-415 3955 Y Y ALL COVERAGE
1707 1592 RSIA. STELLA MARIS MEDAN JL. SAMANHUDI NO.20 MEDAN 061-4158383| 061-4157088 Y Y ALL COVERAGE
1708 0322 RSU. PERMATA BUNDA MEDAN JL. SISINGAMANGARAJA, NO.7061-7362777 / 7360120 / 7367980
EXT. 141|061-7320222 Y N ALL COVERAGE
1709 0626 RS. SARI MUTIARA JL. KAPTEN MUSLIM, NO.79 061-8451812| 061-8452134 Y Y ALL COVERAGE
1710 1649 RS. IMELDA PEKERJA INDONESIA JL. BILAL NO 24 PULO BRAYAN DARAT I MEDAN TIMUR 061-6610072-6631380| 061-6618457 Y Y ALL COVERAGE
1711 1651 RS. BUNDA THAMRIN MEDAN JL. SEI BATANG HARI NO. 28/30 MEDAN SUNGGAL
061-
4553928,88813615,4557318,455721
8,4553918|
061-4558218 Y Y ALL COVERAGE
1712 0590RS. COLUMBIA ASIA MEDAN (D/H GLENI
MEDAN)JL. LISTRIK 2A MEDAN 20112 061-4566368| 061-4566585/4515453 Y Y ALL COVERAGE
1713 4092 RSIA. SRI RATU JL. NIBUNG RAYA NO 204-212 MEDAN 061-4521074| 061-4539236 Y Y ALL COVERAGE
1714 4001 RS. MADANI MEDANJL. A.R. HAKIM NO. 168, KEL. SUKA RAMAI I, KEC. MEDAN
AREA, KOTA MEDAN061-7345911, 061 - 7361357| Y Y ALL COVERAGE
1715 2900 LAB. PRODIA JL. ASIA MEDAN JL. ASIA NO. 115B MEDAN 061-7321260| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1716 1650 RS. MARTHA FRISKA MULTATULI JL. MULTATULI KOMP. MULTATULI INDAH NO 1 MEDAN 061-4149666 / 08286103148| 061-4154761 Y Y ALL COVERAGE
1717 4168 RS. KHUSUS BEDAH SETIA BUDI JL. MESJID NO. 3 TANJUNG REJO, MEDAN (061) 8220995 ; 8220996| (061) 8220955 Y Y ALL COVERAGE
1718 2876 LAB. PRODIA MEDAN S PARMAN JL. LETJEND S PARMAN NO. 17/223 G LT LI 20153 061-4535731 / 4534903| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1719 4091 RSU. SUNDARI JL. TB SIMATUPANG NO 31 MEDAN 061-8452536-|- 061-8452536 Y Y ALL COVERAGE
1720 3779 RS. SILOAM DHIRGA SURYA JL. IMAM BONJOL NO. 6, KEL. PETISAH - MEDAN 20112 (061) 8888 1900 EXT. 22601| (061) 8888 1933 Y Y ALL COVERAGE
1721 3767 PRODIA MEDAN SETIA BUDIKOMPLEKS RUKO MILALA MAS BLOK A NO. 8, SETIA BUDI,
MEDAN(061) 8224129| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1722 3768 PRODIA MEDAN (GATSU) JL. JEND. GATOT SUBROTO NO.129, MEDAN 20112 (061) 4157459| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1723 2028 RS. MITRA SEJATI MEDAN JL. AH. NASUTION PANGKALAN MAHSYUR NO.7, MEDAN 061-7875967/ 7881682| 061-7850261 Y Y ALL COVERAGE
1724 2053 MURNI TEGUH MEMORIAL HOSPITAL JL. JAWA NO. 2 SIMPANG JL. VETERAN 061-80501888/777| 061 - 80501800 Y Y ALL COVERAGE
1725 2182 KLINIK & APOTEK KF 27 JL. PALANG MERAH NO. 32 061-4576023/4515513| 061-451551 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1726 2297 KLINIK GRAND MADANIJL. SETIA BUDI KOMP. SETIABUDI POINT BLOK E 12-13,
MEDAN061-8222345| 061-8222929 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1727 2179 APOTEK FARMARIN MEDAN JL. GATOT SUBROTO NO. 14 KM 4,2 MEDAN PETISAN 061- 4528454| 061- 4528464 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1728 2183 KLINIK & APOTEK KF 39 JL. GATOT SOEBROTO NO 37 A/C 061-4529909| 061-4532717 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1729 2395 SUMATERA EYE CENTER JL. ISKANDAR NO. 278 - 280, MEDAN 061-4525058 ; 4518222| 061-4510978 Y Y ALL COVERAGE
1730 2754 RS. DELI JL. MERBABU NO.18-20, MEDAN (061) 4565229| (061) 4552361 Y Y ALL COVERAGE
Page 39 of 40
MAR-29-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA
29-Mar-17
1731 3957 RS. ROYAL PRIMA MEDAN JL. AYAHANDA NO. 68 A, MEDAN - SUMATERA UTARA (061) 8881 3182; 8881 3183| (061) 8001 3181 Y Y ALL COVERAGE
1732 0416 RS. MATERNA JL. TEUKU UMAR NO.11 061 -4514222| 061-4155392 Y Y ALL COVERAGE
1733 0773 RSU. PROF.DR.BOLONI JL. W. MONGINSIDI NO. 11 MEDAN (061) 4512687; 4556879; 4154637| (061) 4154621 Y Y ALL COVERAGE
1734 0523 RS. ADVENT MEDAN JL. GATOT SUBROTO, KM. 4 061 - 4524875/4574025| 061-4154839 Y Y ALL COVERAGE
1735 0418 KLINIK SPESIALIS BUNDA JL. SISINGAMANGARAJA NO.17 061 -7321666| 061-7344786 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1736 0816 RS. METHODIST JL. MH. THAMRIN, NO.105 (061) 7369000| (061) 7363779 Y Y ALL COVERAGE
PADANG LAWAS
1737 4861 RSU. PERMATA MADINA SIBUHUANJL. KH. DEWANTARA SIHUBUAN KEC. BARUMUN KAB.
PADANG LAWAS, SUMUT(0636) 421211| (0636) 421311 Y Y ALL COVERAGE
PADANG SIDEMPUAN
1738 3771 PRODIA PADANG SIDEMPUAN JL. MERDEKA NO 52 PADANG SIDEMPUAN 22718 (0634) 7366622| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
PEMATANG SIANTAR
1739 0719 RS. VITA INSANI JL. MERDEKA, NO.329 0622-22520| 0622-24521/29133 Y Y ALL COVERAGE
1740 2898 LAB. PRODIA PEMATANG SIANTAR JL. MERDEKA NO 37 PEMATANG SIANTAR 0622-22437| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1741 2209 KIMIA FARMA KARTINI JL. KARTINI NO. 19 PEMATANG SIANTAR 0622-22448| 0622-25527 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1742 2208 KIMIA FARMA 29 SOETOMO JL. SUTOMO NO.63 PEMATANG SIANTAR 0622-22447| 0622-25527 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1743 2984 RS. HARAPAN PEMATANG SIANTARJL. FAREL PASARIBU NO : 21 PEMATANG SIANTAR,
SUMATERA UTARA0622-21162, 21612| 0622-435301 Y Y ALL COVERAGE
1744 4418 KLINIK & APOTEK KF 162 JL. KARTINI PEMATANG SIANTAR -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
RANTAU PRAPAT
1745 3785 LAB. PRODIA RANTAU PRAPAT JL. AHMAD YANI NO. 197, RANTAU PRAPAT 21415 (0624) 25368| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
SIBOLGA
1746 3566 LAB. PRODIA SIBOLGA JL. S. PARMAN NO. 77, SIBOLGA 22523 0631-22539| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
1747 2249 RS. METTA MEDIKAJL. SUTOYO SISWOHARJO NO.34 PASAR BARU, SIBOLGA
KOTA0631-25007/25008/081260753048| 0631-25006 Y Y ALL COVERAGE
TANJUNG BALAI
1748 4120 LAB. PRODIA TANJUNG BALAI JL. SUDIRMAN NO. 23, TANJUNG BALAI - KARIMUN 0623-596227| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-
KM,RM-RB,PHAR
Page 40 of 40
MAR-29-2017