No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
BALI
BADUNG
001 5783 RS. KHUSUS BEDAH BIMC NUSA DUA BALI BLOK D KAWASAN BTDC NUSA DUA 0361-3000911| - Y Y ALL COVERAGE
BANGLI
002 4898 RS. BANGLI MEDIKA CANTI JL. TIRTA GIRI KUTRI LCSUBAK AYA BEBALANG, BANGLI, BALI 0366-91555/93444| - Y Y ALL COVERAGE
BULELENG
003 1451 RSU. PARAMASIDHI JL. A.YANI NO.171A 0362-29787, 32701,22426,| 0362-29787 Y Y ALL COVERAGE
004 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
005 0870 RSU. KERTHA USADA JL. CENDRAWASIH, NO.5-7, SINGARAJA 0362-26277/8| 0362-22741 Y Y ALL COVERAGE
DENPASAR
006 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
007 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
008 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
009 1245 RSU. SURYA HUSADHA UBUNG JL. COKROAMINOTO, NO.356, DENPASAR 0361-425744| 0361-430557 Y Y ALL COVERAGE
010 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
011 1273 RS. SURYA HUSADHA JL. PULAU SERANGAN,NO.7, DENPASAR 0361-233787| 0361-231177 Y Y ALL COVERAGE
012 1309 BALI ROYAL HOSPITAL ( BROS ) JL. TANTULAR NO 6 RENON DENPASAR 0361- 247499/222588/228054| 0361-226051/226052 Y Y ALL COVERAGE
013 1146 RS. BHAKTI RAHAYU DENPASAR JL. GATOT SUBROTO II, NO.110361-430270 / 430245 / 428287 /
7420673|0361-263371 Y Y ALL COVERAGE
014 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
015 0220 RS. PRIMA MEDIKA JL. PULAU SERANGAN, 9X 0361 - 236225/257445/235318| 0361-236203/262535 Y Y ALL COVERAGE
016 0179 RSU. KASIH IBU DENPASAR JL. TEUKU UMAR, NO.120 0361-223036/3003030/082146806677| 0361-238690 Y Y ALL COVERAGE
017 0140 RS. MANUABA JL. HOS. COKROAMINOTO, NO.28 0361-426393| 0361-285183/429447 Y Y ALL COVERAGE
018 0221 RS. PURI RAHARJA JL. WR.SUPRATMAN, NO.14-19, DENPASAR 0361-222013| 0361-242537 Y Y ALL COVERAGE
019 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
020 1047 RS. BALIMED (d/h RS BALI MEDISTRA) JL. MAHENDRADATTA, NO.57X, DENPASAR 0361-484748, 482281,8450771, 8450772| 0361-8450773,8450770 Y Y ALL COVERAGE
021 1147 RS. DHARMA YADNYA JL. WR.SUPRATMAN NO. 256, TOHPATI 0361-462488 / 462629| 0361-464526 Y Y ALL COVERAGE
022 1150 RSIA. PURI BUNDA JL. GATOT SUBROTO VI, NO.19 0361-437999| 0361-433988 Y Y ALL COVERAGE
023 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
024 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
025 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
026 4438 KLINIK UTAMA DHARMA SIDHI JL. SERMA KAWI NO. 13-17, DAUH PURI KELOD, DENPASAR BARAT (0361) 242717; 241013| 361241013 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
027 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
GIANYAR
028 1761 RS. ARI CANTI GIANYAR JL. RAYA MAS UBUD GIANYAR 0361-974573| 0361-974573 Y Y ALL COVERAGE
029 4834 RS. KASIH IBU SABA GIANYAR JL. RAYA PANTAI SABA NO 9 DESA SABA, GIANYAR BALI 0361) 3003333| - Y Y ALL COVERAGE
030 3549 RSU. SANJIWANI GIANYAR JL. CIUNG WANARA N0.2 GIANYAR 0361-943049/0361-943020| Y Y ALL COVERAGE
031 4075 RSU. PREMAGANAJL. HAYANG SANGSI NO.2 PERUM CHANDRA AYU, BANJAR TUBUH, BATU
BULAN - SUKAWATI0361-8461955/ 296389 / 082144049401| 0361-295246 Y Y ALL COVERAGE
032 4666 RS. FAMILI HUSADA JL. ASTINA TIMUR, SAMPLANGAN, KEC.GIANYAR, KAB. GIANYAR (0361) 849 3344| (0361) 8493040 Y Y ALL COVERAGE
JEMBRANA
033 6026 RS. BALIMED NEGARAJl. Hayam Wuruk No. 23 Ds. Dangintukadaya, Kec. Jembrana, Kab.
Jembrana0365-4501452| - Y Y ALL COVERAGE
034 3558 RSU. BUNDA JL. RAJAWALI NO. 36, PENDEM, 0365-40251 / 087863229569| 0365-40089 Y Y ALL COVERAGE
KARANGASEM
035 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
036 4252 RS. BALIMED KARANGASEM JL. NENAS KECICANG BEBANDEM, KARANGASEM, BALI (0363) 4301618| Y Y ALL COVERAGE
KUTA
037 1138 RSU. KASIH IBU KEDONGANAN JL. ULUWATU, NO.69A, KEDONGANAN 0361-703270| 0361-703329 Y Y ALL COVERAGE
038 1909 SILOAM HOSPITALS BALI JL. SUNSET ROAD NO. 818, KUTA 0361-779900| 0361-779933 Y Y ALL COVERAGE
039 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
NUSA DUA
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
041 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
042 1359 RSU. SURYA HUSADHA NUSA DUA JL. SILIGITA, BLOK 1, NO.14 0361-775827| 0361-771388 Y Y ALL COVERAGE
SANUR
043 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
044 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
TABANAN
045 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
046 1714 RS. WISMA PRASANTI JL. YAH GANGGA NO. 9 TABANAN , BALI 0361-8043219/810555| 0361-812454 Y Y ALL COVERAGE
047 3456 APOTIK & KLINIK KIMIA FARMA.102 TABANAN JL. NGURAH RAI NO.74 A TABANAN 0361-810524| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
048 2133 RSU. KASIH IBU TABANAN JL. FLAMBOYAN NO. 9 ( KAMPUNG KODOK ) TEGAL BELODAN TABANAN 0361-3005757| 0361-3005758 Y Y ALL COVERAGE
UBUD
049 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
050 2148 RS. ARSANI JL. RAYA AIR KENANGA KEC. SUNGAI LIAT KAB. BANGKA BLITUNG 0717-4297825, 4297834| 0717-4297824 Y Y ALL COVERAGE
BANGKA TENGAH
051 6122 SILOAM HOSPITALS BANGKA BELITUNG JL. SOEKARNO HATTA KM.5 0710-9190900| - Y Y ALL COVERAGE
BELITUNG
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
053 2370 RS. ALMAH TANJUNG PANDAN JL. JEND. SUDIRMAN KM. 11 NO. 1 KODE POS 33144 0719-9225666| 0719-9225333 Y Y ALL COVERAGE
054 4842 RS. UTAMA TANJUNG PANDANJL. JENDERAL SUDIRMAN KM. 3 RT.019 RW. 008 KEL. DESA LESUNG
BATANG, KEC. TANJUNG PANDAN, KAB. BELITUNG0719-9222211| 0719-9222212 Y Y ALL COVERAGE
055 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
PANGKAL PINANG
056 5045 RSIA. MUHAYAJL. JEND SUDIRMAN NO. 18, TAMAN BUNGA, GERUNGGANG, KEP BANGKA
BLITUNG0717-436997| Y Y ALL COVERAGE
057 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
058 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
059 1508 RS. MEDIKA STANNIA JL. JEND.SUDIRMAN, NO.3, SUNGAI LIAT 0717-95837/93335| 0717-953335 Y Y ALL COVERAGE
060 1443 RS. KHATOLIK BHAKTI WARA JL. SUNGAI SELAN, KM.4, NO.180 0717-422605| 0717-424314 Y Y ALL COVERAGE
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
Page 1 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
061 1230 RS. BAKTI TIMAH PANGKAL PINANG JL. BUKIT BARU NO.1 PANGKAL PINANG 0717-421091| 0717-424212 Y Y ALL COVERAGE
062 5063 PRODIA PANGKAL PINANG JL. KH. ABDURRAHMAN SIDDIQ NO. 176, PANGKAL PINANG 0717-438232| - N Y GP,LAB,PHAR
BANTEN
CILEGON
063 0985 RS. KURNIA CILEGON JL. JOMBANG MASJID NO.4 0254-391161 / 087885829059|- 0254-396489,397023 Y Y ALL COVERAGE
064 2389 KLINIK & RB CIGADING MEDIKA JL. RAYA ANYER KM.7 KUBANGSARI CIWANDAN CILEGON BANTEN 0254-311323| 0254-310568 Y YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
065 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
066 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
067 0057 KLINIK ALFINA JL. RAYA SERANG RUKO PCI BLOK KK I NO 7-8 CILEGON 0254-383116| 0254-377377 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
068 3156 LAB. PRODIA CILEGON JL. SULTAN AGENG TIRTAYASA NO. 8, CILEGON - BANTEN 42414 0254-381990/398969| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
069 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
070 1254 RB & KLINIK AFINA JL. RAMBUTAN 12, PAGEBANGAN - CILEGON 0254-392568| 0254-392568 Y Y ALL COVERAGE
071 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
072 0320 KLINIK BONA MEDIKA FESTIVAL RUKO BONA KARTA BLOK A31-32 CILEGON 0254-387684 / 0818769386| 0254-386699 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
073 0951 KLINIK & APOTEK KF 140 JL. S.A. TIRTAYASA NO 12 0254-399174 / 392278|- 0254-399174 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
074 0939 RSIA. MUTIARA BUNDA CILEGON JL. SA TIRTAYASA RUKO MAISONETTE BLOK B 1-2 SIMPANG TIGA CILEGON 0254- 399988/376888/399968-|- 0254-376454 Y Y ALL COVERAGE
075 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
076 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
077 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
078 1298 KLINIK IKHLAS MEDIKA IV KOMPLEK PONDOK CILEGON INDAH ( PCI ) BLOK A 19 NO.10 0254-395900/7061935/284937| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
079 0915 RS. KRAKATAU MEDIKA JL. SEMANG RAYA - CILEGON0254-396333; 0254-372180; 0254-
372123|0254-3721230254-391972/374010 Y Y ALL COVERAGE
080 1713KLINIK & APOTEK KF 268 PCI CILEGON (GROUP
140)PONDOK CILEGON INDAH BLOK A4 NO.01CILEGON - BANTEN 0254-394827| 0254-376501 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
081 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
082 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
PANDEGLANG
083 1764 KLINIK ALFURQON JL. RAYA LABUAN KM 2 TOROGONG MARGASANA - PANDEGLANG 0253-5808100| 0253-501313 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
084 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
085 1084 RS. MISI LEBAK JL. MULTATULI NO.41 0252-201014-|- 0252-203390 Y Y ALL COVERAGE
086 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
087 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
SERANG
088 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
089 1009 KLINIK IKHLAS MEDIKA 2 JL. RAYA SERANG - JAKARTA KM.04 PAKUPATAN (DEPAN KAMPUS UNTIRTA) 0254-284937-|- - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
090 5285 RSIA. PERMATA SERDANGJALAN WARINGIN KURUNG RT 001/003 DESA SERDANG, KECAMATAN
KRAMATWATU KABUPATEN SERANG, BANTEN 421610254- 387515| 0254-387494 Y Y ALL COVERAGE
091 3993 RS. KURNIA SERANG JL. RAYA CILEGON KM.8, DESA KRAMATWATU SERANG - BANTEN 0254-232648| 0254-8235050 Y Y ALL COVERAGE
092 0716 RS. BUDI ASIH JL. K.H. SOHARI, NO.39 0254-212484/218666| 0254-208583 Y Y ALL COVERAGE
093 3985 KLINIK & APOTEK MURASAKI MEDIKA KOMP.PEJATEN MAS BLOK C/1 PEJATEN KEC.WATU-BANTEN 0254233317| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
094 2413 KLINIK ANDRI MEDISTRA JL. N. RAYA SERANG JAKARTA KM 8 CIRUAS, SERANG - BANTEN -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
095 2392 KLINIK & APOTIK BONA MEDIKA SERANG JL. RAYA SERANG - CILEGON, LEGOK SUKMAJAYA RUKO NO.5A1 0254-228005/ 387684| 0254-205906/386699 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
096 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
097 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
098 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
099 2414 KLINIK JANNAH JL. KH.ABDUL HADI NO.13 KEBUN JAHE SERANG, KAB.BANTEN 0254-209321| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
100 1414 RSIA. PURI GARCIAJL. GRIYA PURNAMA NO 99 TEGAL PADANG LEGOK, SERANG BANTEN
421620254-223333| 0254-223786; Y Y ALL COVERAGE
101 1272 RS. SARI ASIH SERANG JL. JEND.SUDIRMAN, NO.38, PENANCANGAN, CIPOCOK 0254-220022| 0254-220345 Y Y ALL COVERAGE
102 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
103 0115 KLINIK SERANG MEDIKA JL. RAYA SERANG CILEGON RUKO LEGOK SUKMAJAYA BLOK 5C NO.1 0254-223992| 0254-223992 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
104 1004 KLINIK WISATA MEDIKA JL. RAYA ANYER NO.9 0254-600933/605141/ 081905180805-|- 0254-605141 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 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
107 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
108 1126 KLINIK KRAKATAU MEDIKA SERANG JL. TB SUWANDI, KAV KEMUNING NO. 1 LINGKAR SELATAN KEC SERANG 0254-204407| 0254-221397 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
TANGERANG
109 1555 RSIA. DHIA JL. CENDRAWASIH NO.90, SAWAH LAMA CIPUTAT, TANGERANG SELATAN 021-7494550/ 70310242| 021-7494551 Y Y ALL COVERAGE
110 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
111 0308 PAMULANG MEDICAL CENTER JL. RAYA PAMULANG BLOK D II NO.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
112 0610 RSIA. PUTRA DALIMA GRIYA LOKA, SEKTOR 1.2, BLOK UA/26-27, BUMI SERPONG DAMAI021-5380375/5388279021-5388279 /
53741|021-5388279 / 53741021-5381220 Y Y ALL COVERAGE
113 0007 RS. UIN SYARIF HIDAYATULLAH JL. IR. H. JUANDA, NO.95, CIPUTAT 021-30010100/7402718/7499129| 021-7493532 Y Y ALL COVERAGE
114 0062 KLINIK SARANA MEDIKA BARU JL. RAYA PERUMAHAN KOTA BUMI KP.TERITI DS.KARET.SEPATAN 021-5921153 / 02159372781| 021-59308529 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
115 0291 RS. ICHSAN MEDICAL CENTER (IMC) JL. RAYA JOMBANG NO.56 BINTARO SEKTOR IX 021-7456379/ 021-7456386|021-7456386 021-7450819 Y Y ALL COVERAGE
116 0696 KLINIK DOKTER KELUARGA MAWAR JL. KARET RAYA, BLOK 7/69, PERUMNAS TANGERANG 021-5525633; 021-5913616|021-5913616 021-5913616 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
117 0344 RS. QADR KOMPLEK ISLAMIC VILLAGE, KELAPA DUA 021-546 4466; 5463107; 5463106| 021-547 0775 Y Y ALL COVERAGE
118 0064 RB & KLINIK 24 JAM DIANA PERMATA MEDIKA JL. MH. THAMRIN, NO.87C021-5397314/ 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
119 0337 RS. BHINEKA BAKTI HUSADA JL. CABE RAYA NO.17 PONDOK CABE PAMULANG 021-7490018/7490829| 021-7403535 Y Y ALL COVERAGE
120 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
121 0912 KLINIK KARUNIA SEHAT RUKO CIKUPA BLOK B NO.21-23, DEPAN PERUM CITRA RAYA- CIKUPA 021-5963001-|- 021- 59408388 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
122 0702 KLINIK MAHARANIJLN. BOROBUDUR 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
123 0285 RS. MELATI JL. MERDEKA, NO.92 TANGERANG 021-5523945/55776739| 021-55769914/5520028 Y Y ALL COVERAGE
124 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
125 0091 MAYAPADA HOSPITAL TANGERANG JL. HONORIS RAYA, KAV.6, KOTA MODERN/KODYA DATI II 021-5529035/55781999| 021-5529465/5529495 Y Y ALL COVERAGE
126 0022 RS. SARI ASIH KARAWACI JL. IMAM BONJOL NO.38021-552 2794; 021-5523239|021-
5523239021-5525214 Y Y ALL COVERAGE
127 0833 RSIA. BUNDA SEJAHTERA JL. RAYA PURI AGUNG NO 3, KOTA BARU- PASAR KEMIS 021-5925889| 021-5925876 Y Y ALL COVERAGE
128 0844 RSIA. BUNDA SEJATI JL. PRABU SILIWANGI NO.11, JATIUWUNG 021-5900136 / 59315850| 021-5900056 Y Y ALL COVERAGE
129 0859 RS. AMINAH TANGERANGJL. HOS COKROAMINOTO (CILEDUG RAYA) NO.4A KREO SELATAN-
LARANGAN021-7371919/021-7371818|021-7371818 021-7371333 Y Y ALL COVERAGE
130 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
131 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
132 1025 RS. ARIYA MEDIKA JL. INDUSTRI RAYA 1, BLOK A, NO.1-6, JATAKE 021-5902229/5902232-|- 021-5902223/5904951 Y Y ALL COVERAGE
Page 2 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
133 0942 RSIA. MURNI ASIH JL. RAYA BOJONGNANGKA NO 86, MEDANG, PAGEDANGAN TANGERANG021-
36868757/5470263/54200982/546367202021-54204504 Y Y ALL COVERAGE
134 1046 RSIA. PRATIWI JL. RHM NOERADJI, NO.42, KARAWACI021-5520692/71342783021-
43933978|021-43933978021-5224139 Y Y ALL COVERAGE
135 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
136 1168 RSU. BHAKTI ASIH JL. RADEN SALEH, NO.10, KARANG TENGAH 021-7305662/63/021-32575495| 021-73449491/7305652 Y Y ALL COVERAGE
137 0971 RS. ISLAM ASSHOBIRIN JL. RAYA SERPONG KM.11 PONDOK JAGUNG - SERPONG 021-5384314; 021-5374293|021-5374293 021-5374392/5374294 Y Y ALL COVERAGE
138 1116RS. AWAL BROS TANGERANG (D/H RS. GLOBAL
MEDIKAJL. MH.THAMRIN NO.3 KEBON NANAS -CIKOKOL 021-55758888/55780888/55781234| 02155780480/55781545 Y Y ALL COVERAGE
139 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
140 2347 RS. PERMATA PAMULANG JL. RAYA SILIWANGI NO. 1 A, PAMULANG TANGERANG 021-74704999/74709079| 021 - 74709073 Y Y ALL COVERAGE
141 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
142 2469 KLINIK PRATAMA JL. CIRARAB RAYA NO.61 KEC. LEGOK TANGERANG - BANTEN 021- 54260359| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
143 1646 KLINIK JATI ELOKKOMP. BUMI JATI ELOK BLOK A I NO 7, JL. RAYA LEGOK-PARUNG
PANJANG KM. 3,MALANGNENGAH, PAGEDANGAN, TANGERANG, BANTEN021-98496234| 021-5977529 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
144 2774 RSIA. INSAN PERMATAJL. BHAYANGKARA 1 NO.68 KEL. PAKUJAYA, KEC. SERONG UTARA -
TANGERANG SELATAN021-53121344| 021-5396733 Y Y ALL COVERAGE
145 2744 RSIA. AQIDAH JL. RADEN FATAH NO.40 PARUNG SERAB, CILEDUG, TANGERANG 021 73450244, 7319025| 7310851 EXT.222 Y Y ALL COVERAGE
146 2807 KLINIK PERTAMEDIKA PONDOK RANJI JL. WR SUPRATMAN NO. 43 (KAMP UTAN) TANGERANG SELATAN 021-7355253| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
147 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
148 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
149 0021SILOAM HOSPITALS LIPPO VILLAGE
(KARAWACI)JL. SILOAM NO.6, LIPPO KARAWACI 1600 021-80646900| 021-5460921/546008 Y Y ALL COVERAGE
150 1020 RSIA. SELARAS CIKUPA JL. RAYA SERANG KM.18,5 DS BOJONG, KEC CIKUPA KAB. TANGERANG 021-5969145/59401289/021-59401277| 021-59401277 Y Y ALL COVERAGE
151 2504 RS. HERMINA SERPONG JL. RAYA PUSPITEK KM.8 NO.99, SERPONG, TANGERANG SELATAN (021) 7588 4999| 021 - 75883704 Y Y ALL COVERAGE
152 1082 KLINIK TIGA MANDIRI JL. CABE RAYA NO 68D PONDOK CABE, TANGERANG SELATAN 021-7426366-|- 021-7426414 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
153 1552 BUNDA DALIMA HOSPITAL BUMI SERPONG DAMAI, SEKTOR XIV, BLOK J.11, NO.1 021-53154447/8/9| 021-5385062 Y Y ALL COVERAGE
154 1564 RSB. PERMATA SARANA HUSADA PAMULANG PERMAI, BLOK D3, NO.1-2, PAMULANG 021-7407421/22| 021-7496346/7407421 Y Y ALL COVERAGE
155 1527 RSIA. TIARA TANGERANG JL. RAYA SERANG, NO.1, KM.4.5, CIKUPA 021-59401999| 021-5960699 Y Y ALL COVERAGE
156 1528 RSIA ILANUR JL. RAYA SERANG, NO.1, BALARAJA 021-59450898/5953241| 021-5954473 Y Y ALL COVERAGE
157 1547 KLINIK AMIRA GRIYA LOKA SEK 1.6 BLOK A1 NO.3 BSD, TANGERANG SELATAN 021-5384219| 021-53164795 N YGP,SP,OP,DENTAL,MAT,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
158 1324 RSIA. CINTA KASIH JL. CIPUTAT BARU RAYA NO.10 CIPUTAT 021 - 74706020 / 7424639| 021 - 74707986 Y Y ALL COVERAGE
159 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
160 1455 KLINIK PRADHANA RUKO PANORAMA NIAGA NO.14-15 JURUMUDI BARU BENDA 021-55767587| 2159308529 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
161 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
162 1471 KLINIK MELIA MEDIKA KOMP. RUKO DUTA GARDEN SQUARE BLOK C NO 2, TANGERANG 021-51488219/54370568| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
163 1575 MOM & CHILD CARE CLINIC JL.RAYA KELAPA DUA RUKO PDA KAV.25-29 GADING SERPONG 021-54214848 / 083804104440| 021-54209393 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
164 1491 RS. HERMINA TANGERANG JL. KS.TUBUN NO.10 PASAR BARU 021-55772525| 021-5582705 Y Y ALL COVERAGE
165 1594 RSU. DINDA JL. GALUH NO.2 JATIUWUNG, TANGERANG 021-55650577| 021-55652149 Y Y ALL COVERAGE
166 1598 RS. KARANG TENGAH MEDIKA (GROUP YADIKA) JL. KARYAWAN IV, KARANG TENGAH TANGERANG 021-7336699/7335599| 021-7333598 Y Y ALL COVERAGE
167 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
168 1292 RS. MEDIKA BSD JL. LETNAN SOETOPO KAV. KOM. III A NO 7, BSD TANGERANG 021 - 5372296| 021 - 5382296 Y Y ALL COVERAGE
169 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
170 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
171 1637 RS. MULIA INSANI JL. RAYA SERANG KM 16.8 CIKUPA TANGERANG 021-5962790/5962998/5962996| 021-5963099 Y Y ALL COVERAGE
172 1487 RS. MULYA JL. KH.HASYIM ASHARI NO.18 SUDIMARA PINANG 021-7322443; 7322445| 021-7310721/7322445 Y Y ALL COVERAGE
173 1669 RSIA. BUAH HATI CIPUTAT JL. ARIA PUTRA NO 399 SERUA INDAH CIPUTAT - TANGERANG 021-74632222| 021-74638568 Y Y ALL COVERAGE
174 1670 CIPUTRA HOSPITAL JL. CITRA RAYA BOULEVARD BLOK V 00/08 SEKTOR 3,4 KEC PANONGAN 021-59405555| 021-59405678 Y Y ALL COVERAGE
175 1812 SMILE N SHINE DENTAL CARE CENTER ALAM SUTERA TOWN CENTER (ASTC) BLOK 10D NO.6 0816869191 / 021-29008540| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
176 1866 KLINIK SATELIT GSM BINTARO JL. BINTARO JAYA SEKTOR IX RUKO ELANG RAYA KAV.1 NO.10-11 021-7450818| 021-7450642 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
177 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
178 1810 RS. KHUSUS BEDAH THT PROKLAMASI BSDCOMMERCIAL PARK CENTRAL BUSINESS OF DISTRICT BSD KAV.7
TANGERANG SELATAN021-29002929| 021-29002930 Y Y ALL COVERAGE
179 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
180 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
181 1467 RSIA. MUTIARA BUNDA TANGERANG JL. DR. CIPTO MANGUNKUSUMO, NO.3, CILEDUG 021-7301365/73454951| 021-73454952 Y Y ALL COVERAGE
182 1608 RS. SARI ASIH CIPUTAT JL. OTISTA RAYA NO. 3 SASAK TINGGI CIPUTAT, TANGERANG SELATAN 021-7410808| 021-7424445 Y Y ALL COVERAGE
183 1086 RSU. SARI ASIH SANGIANG JL. RAYA MAUK.KM.3,5 SIMPANG TIGA SANGIANG 021-5582732|- 021-55791307 Y Y ALL COVERAGE
184 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
185 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
186 1223 EKA HOSPITAL BSD CENTRAL BUSINESS DISTRICT, LOT IX, BSD CITY 021-25655555| 021-25655544 Y Y ALL COVERAGE
187 1682 RSU. ST CAROLUS SUMMARECON JL. GADING GOLF BOULEVARD KAV. 08 GADING SERPONG 021-54220811| 021-54220810/5422008 Y Y ALL COVERAGE
188 1659 RS. HERMINA CIPUTAT JL. CIPUTAT RAYA NO.2 KERTAMUKTI, CIPUTAT 021-74702525/30492525/30492524| 021-74700999 Y Y ALL COVERAGE
189 6387 AUDY DENTAL BINTARORUKAN VICTORIAN BINTARO BLOK AA NO.03, JL. BINTARO UTAMA SEKTOR
3A, PONDOK AREN, TANGERANG SELATAN(021) 22734928 / 081382154488| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
190 6389 J & J DENTAL CARE TANGERANGJL. RAYA KELAPA DUA PARAMOUNT SPARKS BLOK A NO. 18 KEC. KELAPA
DUA TANGERANG-| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
191 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
192 0737 RS. USADA INSANI JL. KH HASYIM ASHARI NO.24 CIPONDOH, TANGERANG021-55752575/5521270021-
55755665/5521272|021-021-55754335 Y Y ALL COVERAGE
193 1619 RSIA. BUAH HATI PAMULANG JL. RAYA SILIWANGI NO 189 PONDOK BENDA PAMULANG 021-7421149 / 7414488| 021-7420322 Y Y ALL COVERAGE
194 0733 RS. OMNI ALAM SUTERA JL. ALAM SUTERA BOULEVARD KAV.25 SERPONG021-29779999/85550711 - 353438|0711 -
353438021-5312 8666 Y Y ALL COVERAGE
195 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
196 3791 RSIA. CITRA ANANDA JL. RE MARTADINATA NO. 30, CIPUTAT (021) 7401347/ 0852 1795 1795| (021) 7491701 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
197 2081 RS ARIA SENTRA MEDIKA JL. ARIA PUTRA NO. 9 KEDAUNG PAMULANG, TANGERANG SELATAN 15431 021-7499199/ 7401376| 021-7495864/7400956 Y Y ALL COVERAGE
198 1867 KLINIK SATELIT GSO CENGKARENGAREA PERKANTORAN GARUDA SENTRA OPERASI (GSO) GEDUNG
POLIKLINIK GSM BANDARA SOEKARNO-HATTA CENGKARENG021-25601565| 021-5501801 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
199 6002 KLINIK & LAB BETH RAPHA AGAVE INSANIJL. MAULANA HASANUDIN Gg.AMPERA II NO.7-8, PORIS GAGA, BATU
CEPER021-5445855 / 68800855| 021-5445855 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
200 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
201 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
202 2337 KLINIK TUMBUR JL.PAHLAWAN NO.4 SITUGINTUNG REMPOA CIPUTAT TIMUR 0217492818| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
203 6457 KLINIK DARMA NUSANTARA JL. RAYA SERANG KM 9 BITUNG KADU CURUG 021- 5566316| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
204 4697 KLINIK ICHSAN BINTAROKEBAYORAN ARCADE III BLOK KA/E 1-22, JL. BOULEVARD BINTARO JAYA
SEKTOR 7/ BINTARO JAYA - TANGERANG SELATAN 15229(021) 29521655| (021) 2952 1655 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
205 0936 RS. SARI ASIH CILEDUG JL. HOS COKROAMINOTO NO.38 CILEDUG021-7333430/ 33553359021-
7332758|021-7332758021-7333441 Y Y ALL COVERAGE
206 1968 BETHSAIDA HOSPITALDISTRICT TIVOLLI NO.1 PARAMOUNT SERPONG, JL. BOULEVARD RAYA
GADING SERPONG KAV.29021-29309999| 021-29542637 / 39 Y Y ALL COVERAGE
207 4695 RS. TIARA TANGERANGJL. BRINGIN RAYA NO. 3-4-5, KEL. NUSAJAYA, KEC. KARAWACI,
TANGERANG(021) 29238000| (021) 29237999 Y Y ALL COVERAGE
208 3532 CLINIC ICON 8 JL. HORISON BROADWAY BLOK M2 NO. 3 BSD CITY , TANGERANG (021) 33438000/ 021 94588000| (021) 68538820 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
209 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
210 4657 RSIA. BUNJL. RAYA KOSAMBI TIMUR RAYA NO. 2, RT. 011/ RW. 004, KEL. KOSAMBI
TIMUR, KEC. KOSAMBI, TANGERANG, BANTEN(021) 70610735; 29031299| - Y Y ALL COVERAGE
Page 3 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
211 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
212 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
213 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
214 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
215 1774 RS. DR. SUYOTO PUSREHAB KEMHAN JL. RC VETERAN NO. 178 BINTARO 021-7342012 / 73884000| 021-7342581, 7369156 Y Y ALL COVERAGE
216 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
217 0772 MEDIPRO CLINIC PASAR KEMIS PERUM WISMA MAS, BLOK A1, NO.30-31, PASAR KEMIS, KUTA JAYA 021-59318964| 021-59318965 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
218 2360 RS. PERMATA IBU TANGERANG JL. KH. MAS MANSYUR NO.2 KUNCIRAN TANGERANG 021-7334343/ 7300883| - Y Y ALL COVERAGE
TANGERANG SELATAN
219 5550 FRIENDLY DENTAL CARE BSD RUKO BIDEX B16, BSD CITY, SERPONG 021-531164571, 08158939191| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
220 5640 RS. PONDOK INDAH BINTARO JAYA CBC EMERALD BLOK CE/C NO. 01, BOULEVARD BINTARO JAYA 021-80828888| 021-8082 8877 Y Y ALL COVERAGE
221 3047 RSIA. VITALAYA JL. RAYA SILIWANGI NO.1 PERUM PONDOK BENDA INDAH NO.1, PAMULANG 021-7470 3313| 021-74701453 Y Y ALL COVERAGE
BENGKULU
BENGKULU
222 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
223 5415 KLINIK RAWAT INAP RAFAELA KENCANAJL. FLAMBOYAN DESA GIRI KENCANA NO. 104 KETAHUN BENGKULU UTARA,
BENTONG(085268347777)| - N Y ALL COVERAGE
224 0848 RS. TIARA SELLA JL. S PARMAN NO. 61 PADANG JATI, BENGKULU 0736-20350 021-8221574|021-8221574 0736-20626 Y Y ALL COVERAGE
225 1551 RS. BHAYANGKARA BENGKULU JL. VETERAN, NO.2 0736-341086/21553| 0736-349050 Y Y ALL COVERAGE
226 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
227 1021 RS. RAFFLESIA BENGKULU JL. MAHONI NO.10, PADANG JATI 0736-21710|- 0736-342677/21954 Y Y ALL COVERAGE
DAERAH ISTIMEWA YOGJAKARTA
BANTUL
228 1437 RS. PKU MUHAMMADIYAH BANTUL JL. JEND. SUDIRMAN 124-126 0274-368587| 0274-368586 Y Y ALL COVERAGE
SLEMAN
229 4334 RS. HERMINA YOGYAJL. MATARAMAN HERMINA RT 06 RW 50 GONDANGAN RINGINSARI
MAGUWOHARJO, DEPOK0274-2800808/2800909| 0274-2800909 Y Y ALL COVERAGE
230 2974 RSI. YOGYAKARTA PDHI JL. SOLO KM. 12,5 KALASAN, SLEMAN, YOGYAKARTA (0274) 498000| (0274) 498464 Y Y ALL COVERAGE
231 1674 RS. PKU MUHAMMADIYAH UNIT II JL. WATES KM 5,5 GAMPING SLEMAN YOGYAKARTA 0274-6499704/6499706| 0274-6499727 Y Y ALL COVERAGE
232 3088 RSU. QUEEN LATIFA JL. RING ROAD BARAT NO. 118 MLANGI NOGOTIRTO GAMPING SLEMAN 0274-581402| 0274-626309 Y Y ALL COVERAGE
233 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
234 1229 JOGJA INTERNATIONAL HOSPITAL (JIH) JL. RING ROAD UTARA NO.160 CONDONG CATUR 0274-4463535/4463190| 0274-4463444 Y Y ALL COVERAGE
YOGYAKARTA
235 3986 KLINIK THC TIMOHO YOGYAKARTA JL. TIMOHO NO. 86 YOGYAKARTA 0274-5305079| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
236 1255 RS. MATA DR.YAP JL. TEUKU CIK DITIRO, NO.5 0274-562054| - Y Y ALL COVERAGE
237 0747 RS. PANTI RAPIH JL. CIK DITIRO, NO.30 0274-514014/514845/563333| 0274-564583 Y Y ALL COVERAGE
238 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
239 2864 RS. AN NUR JL. N.COLOMBO, NO. 14, YOGYAKARTA 0274-585848/0274-514784| 0271-564110 Y Y ALL COVERAGE
240 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
241 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
242 0077 RS. BETHESDA YOGYAKARTA JL. JEND.SUDIRMAN NO.700274-586688/5622460274 -586688|0274 -
5866880274-563312,521251 Y Y ALL COVERAGE
243 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
244 2617 KLINIK & APOTEK KF 275 JL. KALIURANG KM.6 NO.48 0274-886981/885220| 0274-886981 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
245 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
246 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
247 0991 SILOAM HOSPITALS YOGYAKARTAJL. LAKSDA ADISUCIPTO N0. 32-34 DEMANGAN GONDOKUSUMAN
YOGYAKARTA(0274) 4600 900|- (0274) 4600 922 Y Y ALL COVERAGE
248 1400 RSU. BETHESDA LEMPUYANGWANGI JL. HAYAM WURUK NO.6 0274-512257/588002| 0274-547253 Y Y ALL COVERAGE
249 1286 RS. HAPPYLAND MEDICAL CENTER JL. IPDA TUT HARS. ONO NO. 53, TIMOHO 0274-550060/58| 0274-550061 Y Y ALL COVERAGE
250 0604 RS. LUDIRA HUSADA TAMA JL. WIRATAMA NO.4 TEGALREJO 552440274 2871840/ 620333/620373/0274-
620091|0274-6200910274-589087 Y Y ALL COVERAGE
251 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
252 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
253 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
254 0606 RS. PKU MUHAMMADIYAH YOGYAKARTA JL. K.H. ACHMAD DAHLAN, NO.20 0274-512653-|- 0274-566129 Y Y ALL COVERAGE
DKI JAKARTA
JAKARTA BARAT
255 6428 TOOTH AND TEETH DENTAL CLINICRUKAN PURI BOTANICAL RESIDENCE BLOK I 10 JL. JOGLO RAYA NO.51
KEMBANGAN021-58900413 - 414| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
256 6249 RSUD TAMAN SARI JL. MADU NO.10 KEL MANGGA DUA KEC TAMANSARI JAKARTA BARAT 021-26564276| - Y Y ALL COVERAGE
257 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
258 0782 KLINIK MHT ANGKE JL. TUBAGUS ANGKE NO.27. TAMAN DUTA MAS BLOK D-9B NO.2-3 021- 5675259/5679165| 021-5679165 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
259 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
260 0846 RS. JANTUNG HARAPAN KITA JL. LETJEN S PARMAN KAV.87 SLIPI 021-5684093 / 5684085| 021-5601816 Y Y ALL COVERAGE
261 0943 KLINIK MATA NUSANTARA (KEBON JERUK) JL.ARJUNA UTARA NO.50, KEBON JERUK 11510 (021) 564 6688|- (021) 564 2072 N Y GP,OP
262 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
263 2294 RS. JAKARTA EYE CENTER KEDOYA JL. TERUSAN ARJUNA UTARA NO. 1 KEDOYA, JAKARTA BARAT 11520 021-29221000| - Y Y ALL COVERAGE
264 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
265 1102 RS. BHAKTI MULIA JL. AIPDA K.S.TUBUN, NO.79 021-5481625-|- 021-5331544 Y Y ALL COVERAGE
266 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
267 1479 RS. PONDOK INDAH PURI INDAH JL. PURI INDAH RAYA BLOK S2, KEMBANGAN SELATAN 021-25695222/25695200| 021-25695265 Y Y ALL COVERAGE
268 0736 RSUD. CENGKARENG JL. N. KAMAL RAYA, BUMI CENGKARENG INDAH, CENGKARENG TIMUR 021-54372874/5/6 / 54372882| 021-54374579 Y Y ALL COVERAGE
269 0390 RS. HERMINA DAAN MOGOT JL. KINTAMANI RAYA, NO.2, PERUMAHAN DAAN MOGOT BARU 021-5408989| 021-5449869 Y Y ALL COVERAGE
270 0643 RS. GRHA KEDOYA JL. PANJANG NO 26, KEDOYA UTARA 021-56982222/29910999| 02129910987/56982233 Y Y ALL COVERAGE
271 0381 KLINIK MHT CENGKARENG JL. DAAN MOGOT, KM.17 021-54396298/6194581| 021-6194581 N Y ALL COVERAGE
272 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
273 0836 RS. ROYAL TARUMA JL. DAAN MOGOT NO.34 GROGOL 021-56967788/56958338|- 02156967756/56958589 Y Y ALL COVERAGE
274 0783 KLINIK MHT KALIDERES JL. PETA SELATAN A/2 KALIDERES, JAKARTA BARAT 021- 545602708| 021- 5456027 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
275 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
276 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
277 4353 MITRA KELUARGA KALIDERES JL. PETA SELATAN NO. 1 RT 007/011 KALIDERES 021-22523700| 021-22523702 Y Y ALL COVERAGE
278 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
279 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
Page 4 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
280 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
281 0101 SILOAM HOSPITALS KEBON JERUK JL. RAYA PERJUANGAN, KAV.8, KEBON JERUK021- 25677888/021-5300889|021-
5300889021-5321766 Y Y ALL COVERAGE
282 4492 KLINIK VIVA MEDIKA CENTRO CITYJL. MACAN KAV. 4-5 BLOK S16-S20, 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
283 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
284 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
285 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
286 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
287 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
288 4822 KLINIK MAYAPADA CENTRAL PARKJL. TANJUNG DUREN RAYA GRAND SHOPPING ARCADE BEAUFORT 8 NO.
AC, KEL. TANJUNG DUREN SELATAN, KEC. GROGOL PETAMBURAN, JAKARTA (021) 29859901| - Y Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
289 0018 RS. PELNI JL. AIP II K.S. TUBUN, NO.92-94, PETAMBURAN021-5306901-
9/5349475/5460608/5484809021-0215483145/5306904/7 Y Y ALL COVERAGE
290 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
291 0952 RS. PATRIA IKKT JL. CENDRAWASIH NO.1 KOMP DEPHAN/MABES TNI 021-5308981-84-|- 021-5346387 Y Y ALL COVERAGE
292 5078 RSIA. BINA SEHAT MANDIRIJL. DURI RAYA NO. 22 KEL. DURI KEPA KEC. KEBON JERUK, JAKARTA
BARAT(021) 5669411/12 / 5658870| 021 5603531/5658870 Y Y ALL COVERAGE
293 4686 RS. CIPUTRA CITRA GARDEN CITYJL. BOULEVARD BLOK G-01/01 5 CITRA GERDEN CITY, KRL. PEGADUNGAN
KEC. KALIDERES JAKARTA BARAT 11830(021) 2255 7888| - Y Y ALL COVERAGE
294 6382 AUDY DENTAL GREENVILLE JL RATU KEMUNING BLOK BK NO.6 GREENVILLE (021) 29401060 / 082211700082| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
JAKARTA PUSAT
295 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
296 4238 MP DENTAL CENTERHOTEL INTERCONTINENTAL LG FLOOR R27-28, JL. JEND SUDIRMAN KAV.10-
11, KEL. KARET TENGSIN, KEC. TANAH ABANG(021) 5735336| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
297 2507 MITRASANA IHC KALBE CEMPAKA PUTIH JL. LETJEN SUPRAPTO KAV 4 CEMPAKA PUTIH, JAKARTA PUSAT 021-42873888 EXT : 1451| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
298 4228 RS. LADOKGI JL. FARMASI NO.1, TANAH ABANG, JAKARTA PUSAT (021) 573 3026| - Y Y ALL COVERAGE
299 0788 RSPAD GATOT SUBROTO (PAV.KARTIKA) JL. ABDUL RACHMAN SALEH NO.24021-384 0484, 3441008021-376134|021-
376134021-3859460,3501308 Y Y ALL COVERAGE
300 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
301 1837 E-LAB. S PERCETAKAN NEGARA JL. PERCETAKAN NEGARA NO 17 JAKARTA PUSAT -| - N YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
302 4662 KLINIK & APOTEK KF PPBM BANK MANDIRI JL. RP.SOEROSO NO.2-4 CIKINI 021-2300 181| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
303 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
304 1914 RSUD. TARAKAN JAKARTA JL. KIYAI CARINGIN NO 7, JAKARTA PUSAT 021- 3503150, 3503003, 3842934| 021-3810149, 3503412 Y Y ALL COVERAGE
305 0599 RS. KRAMAT 128 JL. KRAMAT RAYA, NO.128 021-3909814/3918287/3909514| 021-3909125 Y Y ALL COVERAGE
306 1387 BRAWIJAYA CLINIC UOBJL. MH THAMRIN NO.8-9, 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
307 0600 RS. ST. CAROLUS JL. SALEMBA RAYA, NO.41 021-3904441| 021-3922831/3154183 Y Y ALL COVERAGE
308 0029 RSU. EVASARI JL. RAWAMANGUN NO.47 - PRAMUKA 021-4202851/52| 021-4209725 Y Y ALL COVERAGE
309 0787 RS. KHUSUS THT-BEDAH PROKLAMASI JL. PROKLAMASI NO.43021-
3900002/3906893/3144795/3909783|021- 3900947/3152548 Y Y ALL COVERAGE
310 0790 RSIA. BUNDA JAKARTA JL. TEUKU CIK DITIRO NO.28, MENTENG(021) 31922005 / 3143215|(021)
31922005021- 3928583,3928585 Y Y ALL COVERAGE
311 1115 RSPAD GATOT SUBROTO (PAV.IKA) JL. ABDUL RACHMAN SALEH NO.24 021-3504614| 021-3520643 Y N ALL COVERAGE
312 0802 SAHID SAHIRMAN MEMORIAL HOSPITAL JL. JEND.SUDIRMAN, NO.86 021- 57853911|021- 5727210 021- 57853922 Y YH&S,GP,SP,OP,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
313 0398 RS. MH. THAMRIN INTERNASIONAL JL. SALEMBA TENGAH, NO.26-28 021-3904422| 021-3926934,3926931 Y Y ALL COVERAGE
314 0705 KLINIK SWA INDOMEDIKA JL. JEND SUDIRMAN KAV 1, GD BNI 46 LANTAI BASEMENT 1 021-5728987| 021-5728990 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
315 0011 RS. MITRA KELUARGA KEMAYORAN JL. HBR MOTIK LANDAS PACU TIMUR, KEMAYORAN JAKPUS 021-6545555/888| 021-6545959 Y Y ALL COVERAGE
316 1019 RSPAD GATOT SUBROTO (P.DARMAWAN) JL. ABDUL RACHMAN SALEH NO.24021-3840484/3500004/021-376134|021-
376134021-3441903/3859460 Y Y ALL COVERAGE
317 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
318 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
319 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
320 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
321 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
322 1069 RSPAD GATOT SUBROTO(P.IMAM SUJUDI) JL. ABDUL RAHMAN SALEH NO.24 021-3441008-|- 021-3859460 Y N ALL COVERAGE
323 1078 RSIA. BUDI KEMULIAAN JL. BUDI KEMULIAAN NO.25 021-3842828-|- 021-3501012 Y Y ALL COVERAGE
324 1358 RSIA. YPK MANDIRI JL. GEREJA THERESIA, NO. 22 021-3909725| 021-3909806 Y Y ALL COVERAGE
325 1477 BUNDA INTERNASIONAL CLINIC JL. TEUKU CIK DITIRO NO.12, MENTENG 021-29186133.| 021-3926494 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
326 0013 RS. PGI. CIKINI JL. RADEN SALEH, NO.40 021-38997777| 021-324663/ 3910277 Y Y ALL COVERAGE
327 1590 RS. BEDAH THT PROF. NIZAR JL. KESEHATAN NO.9 021- 3503435/34834982| 021-34834982 Y Y ALL COVERAGE
328 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
329 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
330 0953 RS. ISLAM JAKARTA (CEMPAKA PUTIH) JL. CEMPAKA PUTIH TENGAH I/1021-4250451/42801567021-
42801567|021-42801567021-4266546 Y Y ALL COVERAGE
331 1105 RS. JAKARTA EYE CENTER MENTENG JL. CIK DI TIRO 46, MENTENG 021-29221000/31935600|021-31935600 021-3904601 Y Y ALL COVERAGE
332 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
333 0042 RS. PERTAMINA JAYA JL. A. YANI NO.2 021-4204056/4211911|021-4211911 021-4211913 Y Y ALL COVERAGE
334 0135 RS. ABDI WALUYO JL. H.O.S. COKROAMINOTO, NO.31-33 021-3144989| 021-31930866 Y Y ALL COVERAGE
335 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
336 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
337 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
338 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
339 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
340 1232 KLINIK PRODIA HEALTH CARE 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
341 2405 HENDRA HIDAYAT IMPLANT CENTERSAHID SUDIRMAN RESIDENCE LT. 1 UNIT 1, JL. JEND. SUDIRMAN NO. 86
JAKARTA PUSAT021-52970102/104| 021-52970205 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
342 1954 RS. UPN CIPTO MANGUNKUSUMO (KENCANA) JL. DIPONEGORO NO. 71 JAKARTA PUSAT 1500135 , 021 - 92005164| - Y Y ALL COVERAGE
343 1054 RS. HUSADA JL. RAYA MANGGA BESAR 137-139, JAKARTA PUSAT BAG UTARA 021-6260108/021-6490090|021-6490090 021-6497494 Y Y ALL COVERAGE
344 1700 FHL DENTAL CLINIC GEDUNG BRI II LT.15 SUITE 1509 JL. JEND SUDIRMAN NO 44-46 021-57851127/ 57930552| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
345 1702 RS. KHUSUS BEDAH SS MEDIKA JL. SALEMBA I NO 11 JAKARTA PUSAT 021-3913336/3926689| 021-3926687 Y Y ALL COVERAGE
346 1820 RSU. BUNDA JAKARTA JL. TEUKU CIK DITIRO NO.21, MENTENG 021-31923344/ 31922005| 021-31905546 Y Y ALL COVERAGE
347 1495 APOTEK & KLINIK KF INDOSAT GD. INDOSAT LT.23 JL. MEDAN MERDEKA BARAT NO. 1 JAKARTA PUSAT 021-30003750| 021-30003750 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
348 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
349 1026 RSIA. TAMBAK JL. TAMBAK,NO.18 MANGGARAI021-
2303444/087878218215/087880676072|-021-3902550 Y Y ALL COVERAGE
350 1197 RSPAD GATOT SUBROTO (NON. PAV) JL. ABDUL RACHMAN SALEH NO.24 021-3448929| 021-3448929 Y N ALL COVERAGE
351 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
352 4058 KLINIK GRAHA PT YPK MANDIRI GEDUNG GRAHA MANDIRI LT.1 LOBBY SELATAN,JL. IMAM BONJOL NO.61 021 - 39838556| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
353 0084 RS. JAKARTA JL. GARNISUN NO.1 JEND. SUDIRMAN, KAV.49021-5732241/5741828021-5741828|021-
5741828021-5719870 Y Y ALL COVERAGE
354 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
JAKARTA SELATAN
355 0775 RSIA. DUREN TIGA JL. DUREN TIGA RAYA, NO.5, PANCORAN 021- 794 1843 / 7993817 /7948696| 021- 790 1050 Y Y H&S,GP,SP,OP,DENTAL,MAT,LAB,PHAR
Page 5 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
356 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
357 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
358 0911 KLINIK MEDIKA PLAZA KARTIKA CANDRA KARTIKA CHANDRA HOTEL, JL. JEND GATOT SOEBROTO KAV 18-20021-5251207 / 021-5205000|021-
5205000021-5265921 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
359 0400 MEDIKALOKA HEALTHCARE CENTERRDTX TOWER GROUND & 2 ND FLOOR. JL. PROF.DR.SATRIO KAV. E IV NO.6
MEGA KUNINGAN, JAKARTA SELATAN021-5261118| 021-5261119 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
360 2138 KLINIK PERTAMEDIKA PATRA JASA PATRA JASA OFFICE TOWER, JL. JEND. GATOT SUBROTO KAV.32-34 021-5228026/ 5217318| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
361 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
362 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
363 2443 BALI DENTAL CARE JL. PAKUBUWONO VI NO.111 JAKARTA SELATAN (021) 7223391/ 7223391| - N Y DENTAL
364 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
365 2641 KLINIK & APOTEK KF 42 JL. ST. HASANUDDIN NO.1 KEBAYORAN BARU JAKARTA SELATAN 021 7220292| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
366 0957 RSU. PETUKANGAN JL. CILEDUG RAYA NO.8A 021-7340906-|- 021-73889956 Y Y ALL COVERAGE
367 0972 RSU. AULIA JL. JERUK RAYA NO 15 JAGAKARS. A, JAKARTA SELATAN 021-7270208-|- 021-7866057 Y Y ALL COVERAGE
368 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
369 1424 RSIA. ASIH JL. PANGLIMA POLIM I NO.34 JAKARTA SELATAN 12160 021-2700609-10| 021-7255181 Y Y ALL COVERAGE
370 1083 RS. MATA AINI JL. H.R.RASUNA SAID (KUNINGAN) JAKARTA021-5256228/5203866021-5203866|021-
5203866021-5224288/52964781 Y Y ALL COVERAGE
371 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
372 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
373 1089 RS. KHUSUS THT & BEDAH CIRANJANG JL. CIRANJANG NO.20-22 KEBAYORAN BARU021-7243366/7208192/7208192|021-
7208192021-7264038 Y Y ALL COVERAGE
374 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
375 1458 MULIA HEALTH AND DENTAL CARE (MHDC)GEDUNG MENARA MULIA, LG-SUITE 018, 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
376 0799 RS. GANDARIA JL. GANDARIA TENGAH II, NO.12-14, KEBAYORAN BARU 021- 7250718/ 7203311| 021- 7222038 Y Y ALL COVERAGE
377 0800 KLINIK TRIAZ PERSADA GRAHA CIMB NIAGA TOWER LT.B1, JL. JEND. SUDIRMAN KAV.58 021- 2505770 / 2505250| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
378 0193 RSIA. BUDHI JAYA JL. DR. SAHARJO, NO.120021-8292672/8311722021-8311722|021-
8311722021-8301901 Y Y ALL COVERAGE
379 0890 KLINIK INTERMED HEALTH & BEAUTY JL. KEBAGUSAN 1 NO. 8 JAKARTA SELATAN 021-7823501| 021-7823502 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
380 1744 PARAHITA DIAGNOSTIC CENTER MAMPANG JL. WARUNG BUNCIT RAYA NO 150 MAMPANG JAKSEL 021-7949624| 021-7992719 N Y LAB
381 1708 KLINIK PLAZA PT YPK MANDIRI PLAZA MANDIRI LT. BASEMENT I, JL. JEND GATOT SUBROTO KAV 36-38 021-5245351, 5245351| 021-5245351 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
383 0041 RS. AGUNG JL. SULTAN AGUNG, NO.67, PASAR RUMPUT0218294955,8305768/9,8282795,837942
07|021-8305791 Y Y ALL COVERAGE
384 0043 RS. JAKARTA MEDICAL CENTER JL. BUNCIT RAYA, NO.15 021-7980888/7985177 - 7940836/37| 021-7940838 Y Y ALL COVERAGE
385 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
386 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
387 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
388 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
389 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
390 1712 KLINIK SUNFLOWER DENTAL & HEALTH CARE KOMP. BUMI KARANG INDAH JL.KARANG INDAH BLOK A2/4, LOEBAK BULUS 021-29203542/085100106511| 021-29203541 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
391 3710 THOMSON EXECUTIVE HEALTH CENTER TALAVERA SUITE, JL. TB.SIMATUPANG KAV. 22-26 JAKARTA SELATAN (021) 7592 5268| (021) 7592 5269 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
392 1488 RS. ASRI JL. DUREN TIGA RAYA, NO.20 021 27837900 / 021-7995566,7992211| 02179198118/79198733 Y Y ALL COVERAGE
393 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
394 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
395 4340 KLINIK EPICENTRUM MEDICAL CENTEREPIWALK OFFICE SUITES LT. 3 UNIT B 316-317 KOMPLEK RASUNA
EPICENTRUM, JL. H.R RASUNA SAID KEL. KARET KUNINGAN KEC. (021) 2991 2383| (021) 2991 2393 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
396 4413 KLINIK UTAMA CIPUTRA MEDICAL CENTERLOTTE SHOPPING AVENUE FLOOR 5 CIPUTRA WORLD 1, JL. PROF. DR.
SATRIO KAV. 3-5, KEL. KARET KEC. SETIABUDI, JAKARTA SELATAN021-29888137| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
397 4414 AIC - MEDICAL IMAGING DIAGNOSTIC CENTERKUNINGAN CITY MALL B-C -D, JL. PROF SATRIO KAV. 18, JAKARTA
SELATAN 12940(021) 3005 1801/02| (021) 30051803 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
398 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
399 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
400 1872 KLINIK TRIHATI PLUS RUKAN ROYAL PALACE BLOK A5, JL. PROF DR SOEPOMO SH NO 1 021-829 9119| 021-8299113 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
401 1838 E-LAB. S JL. GATOT SUBROTO JL. GATOT SUBROTO KAV 52 JAKARTA SELATAN -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
402 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
403 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
404 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
405 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
406 0228 RSIA. KEMANG MEDICAL CARE JL. AMPERA RAYA, NO.34,KEMANG021-27545454/27545400/021-
6317288|021-6317288021-78843548 Y Y ALL COVERAGE
407 4210 RSIA. ANDHIKAJL. WARUNG SILA no. 8 RT. 006 RW. 04 GUDANG BARU, CIGANJUR,
JAGAKARSA, JAKARTA SELATAN
(021)7874612; 7863408; 78887087;
7863408|(021) 7874612 Y Y ALL COVERAGE
408 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
409 0999 RSU. MUHAMMADIYAH TAMAN PURING JL. GANDARIA I NO.20 KEBAYORAN BARU021-7229623/7250243/7208358|021-
7208358021-7234823/7210516 Y Y ALL COVERAGE
410 0797 RS. MEDISTRA JL. GATOT SUBROTO KAV.49 021-5210200 /| 021-5210184/5 Y Y ALL COVERAGE
411 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
412 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
413 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
414 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
415 0049 RS. PONDOK INDAH JL. METRO DUTA, KAV. UE, PONDOK INDAH 021-7657525| 021-7502324 Y Y ALL COVERAGE
416 2379 KLINIK PRATAMA PALAPA DENTISTSJL. PALAPA I NO. 4 KOMPLEK PERTANIAN PASAR MINGGU JAKARTA
SELATAN 12520021-7806291| 021- 7806291 N Y DENTAL
417 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
418 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
419 4858 KLINIK YEMIMA MEDICAL CENTER JL. RAYA LENTENG AGUNG KEC. JAGAKARSA, JAKARTA SELATAN (021) 29050669| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
420 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
421 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
422 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
423 6431 TEBET DENTAL CLINIC JL. TEBET BARAT 8/18 KEL. TEBET BARAT, KEC. TEBET, JAKARTA SELATAN (021) 8308221/ 8306244| (021) 8202983 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
424 6081 RSIA. KARTINI CILEDUGJL. CILEDUG RAYA NO. 94-96, KEL. CIPULIR KEC. KEBAYORAN LAMA,
JAKARTA SELATAN(021) 7245646/ 7207828| (021) 72792194 Y Y ALL COVERAGE
425 5592 KLINIK THAMRIN TAMAN SARIAPARTEMEN TAMAN SARI SEMANGGI TOWER A UNIT GF.15 JL.AKRI NO.134
RT.008/002, KARET SEMANGGI, SETIABUDI(021) 29888506| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
426 2356MAYAPADA HOSPITAL JAKARTA SELATAN
(MHJS)JL. LEBAK BULUS I KAV.29 021-29536660 / 29208505 / 29217777| 021-29216666 Y Y ALL COVERAGE
427 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
428 0796 RS. METROPOLITAN MEDICAL CENTRE (MMC) JL. HR. RASUNA SAID, KAV. C21, KUNINGAN021-
5203435/0811865958/081617106696|021-5226070/5227060 Y Y ALL COVERAGE
429 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
430 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
431 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
432 4488 KLINIK UTAMA CIPUTRA SMG EYE CLINICLOTTE SHOPPING AVENUE FLOOR 5 CIPUTRA WORLD 1, JL. PROF. DR.
SATRIO KAV. 3-5, KEL. KARET KEC. SETIABUDI, JAKARTA SELATAN(021) 29888138| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
433 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
434 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
Page 6 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
435 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
436 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
437 5904 BIC CLINIC BUNDA PACIFIC PLACE PACIFIC PLACE, LEVEL B1 - 17A, JL. JEND.SUDIRMAN KAV.52-53 021-57973781/93| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
438 2174 SILOAM HOSPITALS SIMATUPANG JL. RA KARTINI NO.8 CILANDAK 021 2953 1900 EXT 22601| 021 759 16997 Y Y ALL COVERAGE
439 2086 KLINIK GLOBAL DOCTOR JLN. WARUNG JATI BARAT NO. 98, LOT 7-9, PEJATEN 021-7194565/ 7980183| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
440 1076 KLINIK YADIKA PETUKANGAN JL. DAMAI RAYA NO.1 PETUKANGAN SELATAN - JAKARTA SELATAN 021-7370881|- 021-73887810 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
441 0110 RS. TRIA DIPA JL. RAYA PASAR MINGGU, NO.3A, PANCORAN 021-7993058,7974071-73| 021-7974074 Y Y ALL COVERAGE
442 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
443 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
444 0842 BRAWIJAYA WOMEN & CHILDREN HOSPITAL JL. TAMAN BRAWIJAYA NO.1 CIPETE UTARA 021 - 7211337/ 021-7247181| 021 - 7211364 Y Y ALL COVERAGE
445 4707 KLINIK MAYAPADAGD. MAYAPADA TOWER II LT.2, JL.JEND.SUDIRMAN KAV.27, KARET,
SETIABUDI(021) 29859988 / 29859999 ext. 806| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
446 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
447 5429 KLINIK UTAMA INDO MEDIKA INTERNATIONALPLAZA 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
448 6380 AUDY DENTAL KEMANG JL BANGKA RAYA NO.40E KEMANG (021) 71794428 / 082122324969| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
449 6388 J & J DENTAL CARE RADIO DALAMJL. RADIO DALAM RAYA NO. 9A RT/RW 008/002 KEL GANDARIA KEC.
KEABYORAN BARU JAKARTA SELATAN021-7207877| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
450 6227 MEDIKA PLAZA WTC 2 CLINIC WTC 2 LOWER GROUND FLOOR JL. JEND. SUDIRMAN KAV 29 021-29522611| 021-29522610 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
451 6483 KLINIK MEDIKA PLAZA BELTWAYBELTWAY OFFICE PARK , GD ANNEX LT. 1 JL. AMPERA RAYA NO. 9-10,
RAGUNAN PASAR MINGGU(021) 30027070| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
452 0003 RS. TEBET JL. LETJEND MT. HARYONO NO.8 KAV.13, PANCORAN 021-8307542/43/44| 021-8311760 Y Y ALL COVERAGE
453 5789 KLINIK UTAMA CONFIDENTA CLINICJL.KEBAGUSAN I NO.4, RT002/01 (KOPINDOSAT), KEBAGUSAN, PASAR
MINGGU021-22780426| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
454 6381 AUDY DENTAL CIPETE JL. CIPETE RAYA NO.55, CIPETE (021) 29124856 / 085775006872| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
455 0593 RS. SETIA MITRA JL. RS. FATMAWATI, NO.80-82, CILANDAK, JAKARTA SELATAN 021-7656000/7651021/7654676| 021-7656880/7656875 Y Y ALL COVERAGE
456 5808 CLINIC 18 GEDUNG 18 OFFICE PARK KAV.18 LANTAI MEZZANINE.M2, KEBAGUSAN 083871523455| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
457 0854 RS. ZAHIRAH JL. SIRSAK NO.21, JAGAKARSA021-78888723/7872210/78888721021-
78888723|021-78888723021-7270013/7872210 Y Y ALL COVERAGE
458 0112 SUDIRMAN MEDICAL CENTER JL. SETIABUDI TENGAH NO.18 021-5203467| 021-5203468 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
459 0795 RS. PUSAT PERTAMINA JL. KYAI MAJA 43, KEBAYORAN BARU (021) 7219555; 7219800| (021) 7203540, Y Y ALL COVERAGE
460 0395 RS. PRIKASIH JL. RS. FATMAWATI, NO.74, PONDOK LAB. U - CILANDAK021-7501192/7504669/75901174021 -
7504669|021 - 7504669021-7505148 Y Y ALL COVERAGE
461 0879 RSU. YADIKA CIPUTAT JL. CIPUTAT RAYA, NO.5, KEBAYORAN LAMA 021-7291074| 021-72895046 Y Y ALL COVERAGE
462 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
463 6231 OMDC DENTAL CLINIC JL. WARUNG BUNCIT RAYA NO.6A 021-79196767| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
JAKARTA TIMUR
464 3531RS. KHUSUS MATA SMEC (SUMATERA EYE
CENTER) JAKARTAJL. PEMUDA NO.36, RAWAMANGUN (021) 4714848| (021) 4755703 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
465 5899 KLINIK UTAMA ASSHOMADIYAH JL. AL.BAIDHO RAYA NO.2A KEL.LUBANG BUAYA, KEC.CIPAYUNG 021-8779 6464| 021-8779 1956 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
466 6011 KLINIK ZAFIRA MEDIKA KAYUMANIS JL. KAYUMANIS TIMUR NO.37 RT 014 RW 002, KAYUMANIS, MATRAMAN 021-85911696| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
467 1843 RSIA. SAYYIDAH JL. TAMAN MALAKA SELATAN NO. 6 PONDOK KELAPA, JAKARTA TIMUR (021) 8690 2950| (021) 864 9886 Y Y ALL COVERAGE
468 6385 AUDY DENTAL PONDOK BAMBU JL. PAHLAWAN REVOLUSI NO.15 PONDOK BAMBU (021) 29622453 / 081298813800| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
469 0749 RS. HARUM SISMA MEDIKA JL. TARUM BARAT, KALIMALANG JAKTIM021-8617212/3 ; 021-8617213|021-
8617213021-8601030 Y Y ALL COVERAGE
470 1706 RSU. PUSAT PERSAHABATAN JL. PERSAHABATAN RAYA NO. 1 021-4891708, 4891745| 2,147,112,224,890,770 Y Y ALL COVERAGE
471 2826 RS. COLUMBIA ASIA PULOMAS JL. KAYU PUTIH RAYA, PULOMAS - JAKARTA TIMUR 13210 (021) 29459999/29559400| (021) 2955 9477 Y Y ALL COVERAGE
472 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
473 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
474 5540 KLINIK TERATAI PONDOK BAMBUJL. PONDOK BAMBU BATAS NO. 14 RT. 003 RW. 02, KEL.PONDOK BAMBU,
KEC. DUREN SAWIT, JAKARTA TIMUR(021) 29361827| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
475 1933 APOTIK FARMARIN II PENGGILINGAN PERUM TAMAN PULO INDAH BLOK I NO.7-8 PENGGILINGAN CAKUNG 021-4800688| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
476 0060 RS. HARAPAN BUNDA JL. RAYA BOGOR KM.22 NO.44 021-8400257| 021-8412977/87780201 Y Y ALL COVERAGE
477 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
478 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
479 1244 RS. MASMITRA JL. KELURAHAN JATIMAKMUR, NO.40, PONDOK GEDE 021-84971766| 021-8483047 Y Y ALL COVERAGE
480 3533 KLINIK MEDIKA PRAKARSA (MEDSA) JL. RADEN INTEN II NO.31 DUREN SAWIT (021) 86908103| 021-86908105 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
481 1217 RSIA. RESTU KASIH JL. RAYA BOGOR, KM.19, NO.3A, KRAMAT JATI 021-8002166/8001177| 021-80882753 Y Y ALL COVERAGE
482 0102 RS. ISLAM JAKARTA TIMUR (PONDOK KOPI) JL. RAYA PONDOK KOPI021-
8630654/29809000/8610471/8610471|02021-8611101/86604256 Y Y ALL COVERAGE
483 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
484 2464 MITRASANA PT JL. PULOGADUNG RAYA KAV.23 RT.010/09, JATINEGARA, CAKUNG 021-29634912 / 89835394| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
485 4431 RS. PUSAT OTAK NASIONAL JL. M.T HARYONO, CAWANG, JAKARTA TIMUR 13630 (021) 2937 3377| (021) 2937 3445; 293 Y Y ALL COVERAGE
486 1080 RS. KESDAM CIJANTUNG JL. MAHONI NO.1, CIJANGTUNG II PASAR REBO 021-8407886/8400535/87793332-|- 021-87793332 Y Y ALL COVERAGE
487 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
488 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
489 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
490 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
491 1868RSIA. AL-FAUZAN (JAKARTA ISLAMIC
HOSPITAL)JL. PEDATI NO 3 RT 5 RW 7, KAMPUNG TENGAH KRAMAT JATI 021-87780318| - Y Y ALL COVERAGE
492 1907 RSIA. SAMMARIE BASRA JL. BASUKI RACHMAT NO. 31, PONDOK BAMBU, DUREN SAWIT 021-86613145| 021-86613147 Y Y ALL COVERAGE
493 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
494 2251 RS. ANTAM MEDIKA JL. PEMUDA RAYA NO 1A PULOGADUNG JAKARTA TIMUR 021- 29378939/40/43/44| 021- 29385160 Y Y ALL COVERAGE
495 2141 KLINIK PERTAMEDIKA MEDAN SATRIA JL. ARUN IX NO. 2 MEDAN SATRIA CAKUNG JAKARTA TIMUR 17132 021-4604944| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
496 2391 RS. JANTUNG JAKARTA JL. MATRAMAN RAYA NO.23, JAKARTA TIMUR 021-29361158/29361160/29360698| 2129361158 Y Y ALL COVERAGE
497 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
498 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
499 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
500 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
501 0990 RS. JANTUNG BINA WALUYA CARDIAC CENTER JL. TB SIMATUPANG NO.71021-87781605-06021-87781606|021-
87781606021-8403869 Y Y ALL COVERAGE
502 1110 RSIA. RESTI MULYA JL. PAHLAWAN KOMARUDIN RAYA NO. 5 PENGGILINGAN CAKUNG 021-4803936-4802192-4803707| 021-48701488 Y Y ALL COVERAGE
503 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
504 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
505 1257 KLINIK PRATAMA MEDIKA KRAMAT JATI JL. BATU AMPAR III NO.55 , RT.011/002 BATU AMPAR, KRAMAT JATI 021-80886446| 021-8016254 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
506 1262 RS. RAWAMANGUN JL. BALAI PUSTAKA RAYA, NO.29-31 021-4893531| 021-4710918 Y Y ALL COVERAGE
507 1538 KLINIK MITRASANA (DANKOS FARMA) JL. RAWA GATEL, BLOK IIIS, KAV.37-38, KAW.INDUSTRI PULO GADUNG 4600158/4600157| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
508 1499 RB & KLINIK ANNISA CIRACAS JL. CIRACAS NO.18 021-87720807/87717636| 021-87717636 Y Y ALL COVERAGE
509 1490 RSIA. BUNDA ALIYAH JL. PAHLAWAN REVOLUSI NO.100 PONDOK BAMBU 021-86602525| 021-86600712 Y Y ALL COVERAGE
510 0888 RS. YADIKA PONDOK BAMBU JL. PAHLAWAN REVOLUSI NO.47 PONDOK BAMBU - JAKARTA TIMUR021-8615754 / 021-8610756|021-
8610756021-8613332 Y Y ALL COVERAGE
511 0289 RS. OMNI MEDICAL CENTER JL. PULO MAS BARAT VI, NO.20 021- 2977 9999| 021-4718081,4708180 Y Y ALL COVERAGE
Page 7 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
512 0012RS. PREMIER JATINEGARA ( RS MITRA
INTERNASIONAL)JL. RAYA JATINEGARA TIMUR, NO.85-87 021-2800666/2800888|021-2800777 021-2800755 Y Y ALL COVERAGE
513 0122 RS. MEDIROS JL. PERINTIS KEMERDEKAAN, KAV.149021-
4750042/4897415/4893036/4895817/472021-4891937 Y Y ALL COVERAGE
514 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
515 0258 KLINIK DEVITA JL. JATINEGARA TIMUR NO.57 JATINEGARA 0218501134/0218516274|021-819 6041 021-85906901/8516274 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
516 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
517 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
518 0806 RS. HAJI JAKARTA JL. RAYA PONDOK GEDE(021) 8000693-95(021) 8000695|(021)
8000695021-80876175/8000152 Y Y ALL COVERAGE
519 0805 RSU. UKI JL. MAYJEN SOETOYO, CAWANG 021-8092317,8010526,8092831,8010523| 021-8092445/8005595 Y Y ALL COVERAGE
520 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
521 0779 RS. AU DR.ESNAWAN ANTARIKSA JL. MERPATI NO.2 LANUD HALIM PERDANAKUSUMA (021) 8007027| (021) 8098 665 Y Y ALL COVERAGE
522 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
523 0826 RB & KLINIK SEJAHTERA CIRACAS JL. RAYA CIRACAS NO.7 021- 87717635/87712710/87712711-|- 021-87720232 Y Y ALL COVERAGE
524 1012 KLINIK IBIN SINA JL.PENDIDIKAN RAYA NO.33 DUREN SAWIT021- 86603270/8661669/86603270|021-
86603270021-86601611 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
525 0944RS. BHAYANGKARA TK.1 R.SAID SUKANTO
(POLRI)JL. RAYA BOGOR KRAMAT JATI RS POLRI 021-8093288|- 021-8095310 Y Y ALL COVERAGE
526 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
527 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
528 0386 RS. HERMINA JATINEGARA JL. RAYA JATINEGARA BARAT, NO.126 021-8513838 / 8191223|021-8504371 021-8190111/8196157 Y Y ALL COVERAGE
529 1001 RS. DHARMA NUGRAHA JL. BALAI PUSTAKA BARU NO.19 RAWAMANGUN021-4707433-37021-4707437|021-
4707437021-4707429/8 Y Y ALL COVERAGE
530 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
JAKARTA UTARA
531 1033 RS. PORT MEDICAL CENTER JL. ENGGANO NO.10 TANJUNG PRIOK 021-43902350/43902351-|- 021-43902302 Y Y ALL COVERAGE
532 0919 RS. PELABUHAN JAKARTA JL. KRAMAT JAYA, TANJUNG PRIOK 021-4403026|021-4403026 021-4403551/4406886 Y Y ALL COVERAGE
533 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
534 2458 RSIA. GRAND FAMILYJL. PANTAI INDAH SELATAN 1, KOMP.ELANG LAUT BOULEVARD KAV.1 NO.1,
PENJARINGAN021-29673737/29678062/296333777| 021-29673747 Y Y ALL COVERAGE
535 6384 AUDY DENTAL PANTAI INDAH KAPUK JL. PANTAI INDAH SELATAN 1, RUKO ELANG LAUT BLOK NO.20 (021) 29219170 / 081291303052| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
536 1644 KLINIK SYIFA MEDICAL CENTRE JL. LONTAR LUAR NO.7 RT 004/04 TUGU UTARA KOJA KEC. KOJA 021-43935260| 021-43935375 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
537 0170 RS. PLUIT JL. RAYA PLUIT SELATAN, NO. 2 021-6685006; 021-668507|021-668507 021-6684878 Y Y ALL COVERAGE
538 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
539 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
540 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
541 6383 AUDY DENTAL KELAPA GADING RUKO MAL OF INDONESIA BLOK K NO.3 KELAPA GADING (021) 45869153 / 082298757541| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
542 6390 J & J DENTAL CARE PENJARINGANRUKO CORDOBA BLOK G NO. 16 JL. MARINA RAYA INDAH GOLF NO.2
KEL.KAMAL MUARA KEC. PENJARINGAN JAKARTA UTARA-| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
543 0882 RS. ISLAM JAKARTA UTARA ( SUKAPURA ) JL. TIPAR CAKUNG NO.5 JAKARTA UTARA021-4400781,4400778021-4400778|021-
4400778021-44832228,4400782 Y Y ALL COVERAGE
544 4733 CLINIC PROTERA KIRANA BOUTIQUE OFFICE F2 NO. 1-2, KELAPA GADING, JAKARTA 14240 (021) 29365237| (021) 2936 5242 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
545 4079 RS. DUTA INDAHJL. TELUK GONG RAYA NO 12 RT.007/007 KEC. PENJARINGAN
KEL.PENJAGALAN JAKARTA UTARA(021) 6667 6188| (021) 6667 6190 Y Y ALL COVERAGE
546 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
547 3732 KLINIK 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
548 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
549 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
550 0748 RS. GADING PLUIT JL. BOULEVARD TIMUR RAYA, KELAPA GADING. JAKARTA UTARA021-4521001/4520201021-4520201|021-
4520201021-4520390 Y Y ALL COVERAGE
551 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
552 1813 FRIENDLY DENTAL CARE JL. DANAU SUNTER UTARA BLOK C1 / 4 B JAKARTA UTARA 021-65836485| 021-65836484 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
553 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
554 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
555 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
556 2506 MITRASANA KELAPA GADINGJL. BOULEVARD TIMUR RAYA BLOK NB I NO 36 KELURAHAN PEGANGSAAN
DUA, KELAPA GADING JAKARTA UTARA021-36464908/4585455| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
557 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
558 1269 RS. MULYASARI JL. RAYA PLUMPANG SEMPER NO. 19 JAKARTA UTARA 021-43931111-43936666-43939999| 021-43934369/8888 Y Y ALL COVERAGE
559 1422 ROYAL PROGRESS INT HOSPITAL JL. DANAU SUNTER UTARA, SUNTER PARADISE I 021- 6400261; 6459877| 021-6519534 Y Y ALL COVERAGE
560 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
561 0186 RS. MITRA KELUARGA KELAPA GADING JL. BUKIT GADING RAYA KAV.2 KELAPA GADING PERMAI 021-45852700| 021-45852727/4585404 Y Y ALL COVERAGE
562 0812 RS. ATMA JAYA JL. PLUIT RAYA NO.2 (021) 6606127| (021) 6606122 Y Y ALL COVERAGE
563 0811 RS. SUKMUL JL. TAWES NO.18 - 20, TANJUNG PRIOK 021- 4301269| 021- 4301272 Y Y ALL COVERAGE
564 0396 RS. PANTAI INDAH KAPUK JL. PANTAI INDAH UTARA 3, PANTAI INDAH KAPUK 021-5885066; 5885065| 021-5880910/5881091 Y Y ALL COVERAGE
565 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
566 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
GORONTALO
GORONTALO
567 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
568 1420 RSIA. SITTI KHODIJAH GORONTALO JL. NANI WARTABONE NO. 101 d/h JL. AHMAD YANI 0435-822130/0435-821253/0435-824410| 0435-824410 Y N ALL COVERAGE
569 1513 RSU. BUNDA GORONTALO JL. HB.JASSIN, NO.269, KOTA GORONTALO0435-829255/ UGD
830600/827573/829290|0435-827573 Y N H&S,MAT
Page 8 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
JAMBI
JAMBI
570 0894SILOAM HOSPITALS JAMBI (D/H RS. ASIA
MEDIKA)JL. SOEKARNO - HATTA, PAALMERAH JAMBI 0741-5919000-|- 0741-573271/573238 Y Y ALL COVERAGE
571 0550 RS. ST.THERESIA JL. SUTOMO, NO.19 0741 - 23119 / 7553811| 0741-20832 Y Y ALL COVERAGE
572 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
573 2184 APOTEK KIMIA FARMA 208 JL. SOEMANTRI BROJONEGORO NO. 108877800501/082146383275/074170785
71|- N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
574 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
575 2047 RSIA. ANNISA JAMBI JL. KABIA NO 04 RT 01 KEL. KEBUN HANDIL KEC JELUTUNG KOTA JAMBI (0741) 445226| - Y Y ALL COVERAGE
576 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
577 2372 RS. KAMBANG JAMBI JL. KOL. AMIR HAMZAH N0 53, KEL SELAMAT KEC.JELUTUNG JAMBI 36129 0741-61714| - Y Y ALL COVERAGE
MUARA BUNGO
578 1926 RS. SENTRAL MEDIKA MUARA BUNGO JL. RANGKAYO HITAM, CADIKA MUARA BUNGO, JAMBI 0747-22207/22209| 0747-22209 Y Y ALL COVERAGE
579 5615 RSIA. PERMATA HATI MUARA BUNGOJL. LEBAI HASAN RT. 06 RW. 02 KEL. SUNGAI PINANG, KEC. BUNGO DANI,
KAB. BUNGO
(0747) 7331122/ 7331123, Hp. 0821 8461
2206|(0747) 7331123 Y Y ALL COVERAGE
JAWA BARAT
BANDUNG
580 1087 RS. BUNGSU JL. VETERAN, NO.6 022-4231550-|- 022-4231582 Y Y ALL COVERAGE
581 1088 RS. RAJAWALI JL. RAJAWALI NO.38022-6031087, 6011913,
6079143,6051087-|-022-6032077 Y Y ALL COVERAGE
582 1093 RS. KHUSUS BEDAH HALMAHERA SIAGA JL. LL.RE MARTADINATA NO.28 022-4206061/70858254/4216436-|- 022-4236920 Y Y ALL COVERAGE
583 1515 RSIA. MELINDA JL. PAJAJARAN, NO.46 022-4222788,4222388,4209088,4266700| 022-4215700 Y Y ALL COVERAGE
584 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
585 4123 LAB. PRODIA MTC METRO INDAH MALL BLOK B NO.5, JL. SOEKARNO HATTA, BANDUNG 022-7536256| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
586 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
587 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
588 4682 KLINIK UTAMA BANDUNG EYE CENTER JL. SUMATERA KEBON PISANG, KEC. SUMUR BANDUNG, BANDUNG (022) 4214390| - N Y ALL COVERAGE
589 1578 RS. HERMINA ARCAMANIK JL. AH.NASUTION, KM.7, NO.50 ARCAMANIK 022-87242525| 022-7271771 Y Y ALL COVERAGE
590 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
591 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
592 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
593 2734 RSU. PINDAD JL. JEND. GATOT SUBROTO NO.517 (PAPANGGUNAN) BANDUNG 40285 022-7322877/7309807| 022-7322468 Y Y ALL COVERAGE
594 4237 RSIA. GRHA BUNDA JL. TERUSAN JAKARTA NO. 15-17 BANDUNG, JAWA BARAT 022-872 56789| 022-872 56000 Y Y ALL COVERAGE
595 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
596 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
597 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
598 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
599 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
600 0303 RS. ADVENT BANDUNG JL. CIHAMPELAS, NO.161 022 -2034386-9/2034388| 022-2043167/2041109 Y Y ALL COVERAGE
601 1900 TELEMEDIKA HEALTH CENTER (THC) SENTOT JL. SENTOT ALIBASYAH NO 4 BANDUNG 022-61115555| . N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
602 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
603 1170 RS. SANTO YUSUP JL. CIKUTRA 7 BANDUNG022-7208172,022-7217097, 022-
7217103, 022-7231721|022-7202419 Y Y ALL COVERAGE
604 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
605 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
606 2213 TELEMEDIKA FARMA 2 BB JL. TERUSAN BUAH BATU NO 33 022-70348587| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
607 1687 RS. IMC BANDUNGJL.RAYA CIMAREME NO.170-173 NGAMPRAH, PADALARANG, BANDUNG
BARAT022-6620923/6620965| 022 - 6620964 Y Y ALL COVERAGE
608 0886 RSUD. AL IHSAN JL. KIASTRAMANGALA, BALEENDAH,022-
5940872/5941719/5941729/5940770/877022-5941709 Y Y ALL COVERAGE
609 1169 RS. AMC (ANNISA MEDICAL CENTER) JL. RAYA CILEUNYI RANCAEKEK 022-7781630,70804777,70805777| 022-70804777/7781629 Y Y ALL COVERAGE
610 1171 SANTOSA BANDUNG INTERNASIONAL HOSPITAL JL. KEBON JATI, NO.38 022-4248333| 022-4211086/84468598 Y Y ALL COVERAGE
611 0958 KLINIK AN-NUR JL. DR. SETIA BUDI NO.63 022-2031922; 022 2042213|- 022-2031922/2042213 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
612 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
613 0145 RS. MUHAMMADIYAH BANDUNG JL. KH. AHMAD DAHLAN NO.53022-
7301062,7312167,7323549,7306935,7323022-7306458 Y Y ALL COVERAGE
614 0761 RS. SANTO BORROMEUS BANDUNG JL. IR.H.JUANDA NO.100 LEBAK GEDE COBLONG022-2552041/82558000/022-2552083/95;
022-2552003.|022-2552003022-2504235 Y Y ALL COVERAGE
615 6364 RS. KARISMA CIMAREME Jl. RAYA CIMAREME NO.235 NGAMPRAH, BANDUNG BARAT 022-6866221| 022-6867821 Y Y ALL COVERAGE
616 5900 RSU. BINA SEHAT JL. RAYA DAYEUH KOLOT NO.325 (022)5207963-65| 022-5207964 Y Y ALL COVERAGE
617 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
618 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
619 6391 RS MATA BANDUNG EYE CENTER JL. BUAH BATU NO.147 RT.007/006 LENGKONG, TURANGGA (022) 7351 4683/84| (022) 7351 4682 Y Y ALL COVERAGE
620 0044 RSU. HERMINA PASTEUR JL. DR. DJUNDJUNAN, NO.107, PASTEUR 022-6072525| 022-6037815 Y Y ALL COVERAGE
621 0144 RS. IMMANUEL BANDUNG JL. KOPPO, NO.161022-5201051/5201672/5201656|022-
5224216022-5224219 Y Y ALL COVERAGE
622 1265 APOTEK & KLINIK KIMIA FARMA SULAJANA 4 JL. SULAJANA NO.4 022-85880430/91512935| 022-4261088 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
623 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
624 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
625 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
626 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
627 5119 KLINIK BRAWIJAYA BANDUNG JL. KH. ACHMAD DAHLAN 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
628 1125 RS. CAHYA KAWALUYAN JL. PARAHYANGAN KM.3 KAV.HOS PADALARANG 022-6803700| 022-6803711/6803730 Y Y ALL COVERAGE
629 0880 RS. AL ISLAM BANDUNG JL. SOEKARNO-HATTA NO.644022-7562046 / 022-7563231|022-
7563231022-7563233/7500109 Y Y ALL COVERAGE
630 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
631 6374 KLINIK JASMINE MQ MEDIKA JL. DAYANG SUMBI NO.10 RT.03/03 LEBAK SILIWANGI, COBLONG 022-20454500 / 20454502| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
632 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
633 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
634 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
635 1829 RSIA. LIMIJATI JL. LAKS L RE MARTADINATA 33-39 022-4207770/022-84281333/84469472| 0224-4260956 Y Y ALL COVERAGE
636 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
637 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
638 2936 LAB. PRODIA BUMI MAS KENCANA RUKO BUMI MAS KENCANA, JL. AH. NASUTION 928 B CIKADUT BANDUNG 022-7236559| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
639 3366 SANTOSA HOSPITAL BANDUNG KOPO JL. K.H. WAHID HASYIM (KOPO), NO.461-463 BANDUNG 022-54280333| 022-5402242/54280365 Y Y ALL COVERAGE
Page 9 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
BANJAR
640 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
641 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
642 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
643 6386 AUDY DENTAL BEKASI RUKO GRAND GALAXY CITY BLOK RGG NO.26 (021) 82733123 / 081212026161| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
644 6069 KLINIK CIPTO 2JL. RAYA CIKARANG SUKATANI NO. 3 DESA KARANG SENTOSA KEC.
KARANG BAHAGIA KAB. BEKASI(021) 89161455| (021) 89161455 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
645 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
646 2821 LAB. PRODIA BEKASI JL. KH NOER ALI NO.90 RT.01 RW.25 KAYURINGIN JAYA, BEKASI SELATAN. (021) 8840480, 8844911| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
647 2513 MITRASANA MEGA REGENCY 2"Jl.Perum Mega regency Blok A09 Desa Sukasari Kec. Serang baru kab.
Bekasi0815101487758| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
648 1989 RSIA. KARUNIA KASIH (KARUNIA BUNDA) JL. RAYA JATI WARINGIN NO. 133 PONDOK GEDE KOTA BEKASI 021-8461970| 021- 8460991 Y Y ALL COVERAGE
649 5795 KLINIK PRATAMA IMANI MEDIKAJL. RAYA TAMAN NAROGONG INDAH BLOK A10 NO.3, PENGASINAN,
RAWALUMBU(021) 82731078| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
650 6010 RS. TARUMAJAYA JL. RAYA TARUMAJAYA NO.1B KP.BALI, PANTAI MAKMUR, TARUMAJAYA 021-88992337 / 88992338| Y Y ALL COVERAGE
651 6068 PRESIDENT MEDICAL CENTERJL. KI HAJAR DEWANTARA NO.81-83, KAWASAN PENDIDIKAN JABABEKA
RUKO INFO PLAZA CIKARANG BARU021-29469400 / 29082423| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
652 2036 RSU. DR. IQBALI TAUFANVILA MUTIARA CIKARANG 2 BLOK E3 NO.16-20 SUKASEJATI, CIKARANG
SELATAN - BEKASI021-8971769/89902361| 021-89902361 Y Y ALL COVERAGE
653 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
654 1296 RSB. TAMAN HARAPAN BARUJL. TAMAN HARAPAN BARU RAYA, BLOK R-I NO.20, PEJUANG - MEDAN
SATRIA021-88871202| 021- 88871203 Y Y ALL COVERAGE
655 0847 RS. ANNA PEKAYON JL. PEKAYON RAYA NO.36, BEKASI SELATAN 021-82432211| 021-82419079 Y Y ALL COVERAGE
656 1261 RS. HOSANA MEDICA BEKASI JL. PRAMUKA NO.12 RAWA LUMBU 021-8221570/73| 021-8224604/8221574 Y Y ALL COVERAGE
657 5902 RS. SATRIA MEDIKA JL. RAYA BANTAR GEBANG - SETU NO.119, PADURENAN, MUSTIKAJAYA 021-22105678| - N Y ALL COVERAGE
658 1062 RS. CIBITUNG MEDIKA JL. RAYA H.BOSIH NO.117 DS.WANASARI,CIBITUNG 021-88323444/88393181-|- 02188323449/88372866 Y Y ALL COVERAGE
659 1333 RSU. KARTIKA HUSADA JATIASIH JL. SWANTARA NO 72 JATI ASIH, BEKASI 021-82435585-82435587| 021-82435586 Y Y ALL COVERAGE
660 0178 RS. HERMINA BEKASI JL. KEMAKMURAN, NO.39, MARGAJAYA 021-8842121/30| 02188865121/88952275 Y Y ALL COVERAGE
661 6250 RS. AWAL BROS BEKASI TIMUR JL. H.M JOYOMARTONO, MARGAHAYU, BEKASI TIMUR (021) 8267 9999| (021) 8267 8989 Y Y ALL COVERAGE
662 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
663 1053 RS. ST. ELISABETH - BEKASI JL. RAYA NAROGONG NO.202 KEMANG PRATAMA021-82430101/82400186/8229767021-
82432082|021-82432082021-82432083 Y Y ALL COVERAGE
664 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
665 1304 RS. PUSPA HUSADAJL. RAYA PONDOK TIMUR KM. 1, NO 27 JATIMULYA TAMBUN SELATAN-
BEKASI021-82618978/82618979| 021-82618977 Y Y ALL COVERAGE
666 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
667 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
668 5221 RS SILOAM BEKASI TIMUR d/h 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 Y Y ALL COVERAGE
669 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
670 5223 VIVA MEDIKA CIKARANGRUKO CIKARANG CENTRAL CITY BLOK F NO. 23, JL. CIKARANG CIBARUSAH
DESA CIANTRA KEC. CIKARANG SELATAN, BEKASI(021) 2961 9212| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
671 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
672 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
673 0010 RS. MITRA KELUARGA BEKASI BARAT JL. JEND. A.YANI, BEKASI BARAT 021-8853333| 021-8842550/8855000 Y Y ALL COVERAGE
674 2544 MITRASANA TAMAN CENTURYJL. RAYA LASKAR NO.59 RT.004/02, KEL.PEKAYON JAYA, KEC.BEKASI
SELATAN085100487742| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
675 0766 RS. ANANDA BEKASI JL. SULTAN AGUNG NO.173, MEDAN SATRIA 021-8854338| 021- 88950141 Y Y ALL COVERAGE
676 0843 KLINIK DHARMA BHAKTI JL. RAYA BOSIH BLOK A4 NO.23 PONDOK TANAH MAS, CIBITUNG - BEKASI 021-8831441-|- 021-8831441/8830246 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
677 4515 PRODIA SUMMARECON BEKASI JL. BULEVAR SELATAN SUMMARECON BEKASI RUKO SINPASA BLOK SA 021-8840480| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
678 1350 RS. MITRA KELUARGA CIBUBUR JL. ALTERNATIF TRANSYOGI, CIBUBUR 021-84311771/84311777| 021-84311661 Y Y ALL COVERAGE
679 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
680 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
681 4814 KLINIK MULTAZAMJL. RAYA CIBARUSAH NO. 33KEL. SUKARESMI, KEC. CIKARANG SELATAN,
BEKASI(021) 9874929| - N Y ALL COVERAGE
682 1558 KLINIK ASYIFA HUSADA PERUM. VILLA MUTIARA JAYA BLOK N. 78 /11-12, WANAJAYA, CIBITUNG 021-88338235| 021-88338235 N YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
683 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
684 4693 RS. CIKUNIR JL. RAYA CIKUNIR GG. HJ NAPSIAH RT.06/03 , JAKAMULYA (021) 82437322| (021) 82437323 Y Y ALL COVERAGE
685 3956 APOTEK KIMIA FARMA CAHAYA AMALIA JL. KH.MUCHTAR TABRANI NO.3-4, KEL.PERWIRA BEKASI UTARA 02188879888| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
686 4484 KLINIK & RB KARUNIA MEDIKA CENTER JL. GATOT SUBROTO NO. 37 RT.003/002 KEL. CIKARANG - BEKASI 021-89104266| - N YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
687 4811 RSU. AS-SHOFWANJL. RAYA KARAWANG BEKASI KM 30 DS. BOJONGSARI KEDUNGWARINGIN
KAB. BEKASI(021) 89141890| (021) 89141754 Y Y ALL COVERAGE
688 1123 RS. CITRA HARAPAN JL. RAYA HARAPAN INDAH KAW.SENTRA NIAGA NO.3-5 MEDAN SATRIA 021-88870606/88870909/88865792-93| 021-88975555 Y Y ALL COVERAGE
689 2511 MITRASANA DUKUH ZAMRUD JL. ZAMRUD UTARA RUKO BLOK S.1 NO. 18 KOTA LEGENDA,BEKASI TIMUR 08891258897/ 82602911| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
690 4815 RS. PERMATA KELUARGA JABABEKA JL. DR.CIPTO MANGUNKUSUMO BLOK A NO.1A, MEDICAL CITY JABABEKA ( 021 ) 29083399| (021) 8990 1860 Y Y ALL COVERAGE
691 0891 RS. HERMINA GALAXY JL. GARDENIA RAYA SELATAN BLOK BA1 NO.11 021-8222525/82417777| 021-82414087 Y Y ALL COVERAGE
692 2433 KLINIK TAMAN FIRDAUS MEDIKA PERUM TAMAN FIRDAUS RESIDENCE BLOK A 06 NO.17 CIBARUSA BEKASI 021 - 89950047| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
693 2573 MITRASANA BUMYAGARA TAMAN BUMYAGARA A.04 KEL MUSTIKA JAYA 085100464921| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
694 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
695 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
696 2585 MITRASANA WIBAWA MUKTI JL. WIBAWA MUKTI RT.01/11 KP.PEDURENAN, JATIASIH 021-36487743| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
697 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
698 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
699 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
700 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
701 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
702 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
703 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
704 0161 RS. MITRA KELUARGA BEKASI TIMUR JL. PENGASINAN RAWA SEMUT MARGAHAYU, BEKASI TIMUR 021-8817777/89999222| 8820707/89999286 Y Y ALL COVERAGE
705 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
706 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
707 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
708 1971 RB. WIJAYANTIJL. PERUM GRIYA BEKASI PERMAI BLOK H6 NO 17, TELAJUNG-CIKARANG
BARAT021-29371856/97958619| 021-82602243 Y Y ALL COVERAGE
709 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
710 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
711 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
712 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
713 1807 RS. TIARA BEKASI JL. RAYA BABELAN NO. 63 KEL. KEBALEN KEC. BABELAN KAB. BEKASI 021-89131111/021-89133333| 021-89132039 Y Y ALL COVERAGE
714 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
715 1816 RS. HARAPAN MULIA JL. RAYA CIBARUSAH NO. 5 KB. KOPI, CIBARUSAH JAYA KAB. BEKASI 021-89952340| 021-89952460 Y Y ALL COVERAGE
Page 10 of 28
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
716 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
717 1937 APOTIK FARMARIN VII BEKASIJL. GURAME RAYA PERTOKOAN KAV.29 PERUMNAS KAV.29 PERUMNAS II
KEL, KAYU RINGIN RAYA KEC BEKASI SELATAN.02188968419| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
718 1924 KLINIK MANDIRI PERUM VILLA MUTIARA CIKARANG BLOK R 26-27 CIKARANG SELATAN 021-897 4883| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
719 1530 KLINIK SIERRA MITRA JL. KH. M.TABRANI BLOK I NO. 1 A-1B, MARGAMULIA, BEKASI UTARA 021-70266392/8868129| 021-8868129 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
720 1541 RS. PERMATA BEKASI JL. LEGENDA RAYA, NO. 9, MUSTIKA JAYA 021-8251919/8254748| 021-82609705 Y Y ALL COVERAGE
721 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
722 1122 RS. JATI SAMPURNA JL. STUDIO ANTV KRANGGAN 021-8451457/8455874| 021- 8455712/8459464 Y Y ALL COVERAGE
723 1576RS TAMAN HARAPAN BARU (d/h praktek
bersama dokter)JL KALIABANG TENGAH RT 04/23 KEL. PEJUANG KEC. MEDAN SATRIA 021-88981055| 021-88981055 Y Y ALL COVERAGE
724 0063 RS. MULTAZAM MEDIKA JL. PERUMAHAN JATIMULYA NO.1 TAMBUN SELATAN021-8215101/8215102021-8215102|021-
8215102021-82416678 Y Y ALL COVERAGE
725 1553 RS. HERMINA GRAND WISATA JL. FESTIVAL BOULEVARD BLOK JA NO. I, GRAND WISATA 021-8265 1212| 021-825 2963 Y Y ALL COVERAGE
726 0016 RS. KARYA MEDIKA CIBITUNG JL. RAYA IMAM BONJOL, NO.9B, CIKARANG BARAT, CIBITUNG021-8900190-1& 8903003-4/ 8900190-1
(ext:181)|021-89107753-4 Y Y ALL COVERAGE
727 1588 RB. ASYIFA HUSADA MEDICAL CENTER PERUM. BEKASI REGENCY I BLOK K I NO. 1, CIBITUNG 021-88332152| 021-88332152 Y Y ALL COVERAGE
728 1595 KLINIK VNV MEDIESTETIKOMPLEK PEMDA BLOK C KAV 60 B, JL WARUNG BUAH KOMSEN JATI ASIH
BEKASI021-824 15167/ 82435767| 021-82435767 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
729 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
730 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
731 1586 RS. BUNDA MULIA (d/h) RSIA SRITINA JL. IMAM BONJOL NO.80A CIKARANG BARAT, BEKASI 021-8900579-89106317| 021-89106633 Y Y ALL COVERAGE
732 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
733 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
734 1771 RS. KARTIKA HUSADA SETU JL. BURANGKENG RT 01/06 DESA BURANGKENG SETU BEKASI 021-82610003/4/5| 021- 82610005 Y Y ALL COVERAGE
735 0032 RB. BUNDA AUNI VILLA NUSA INDAH, BLOK D5, NO.19 021-82402286/82420366/82403873| 021-82410136 Y Y ALL COVERAGE
736 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
737 0185 RS. BHAKTI KARTINI JL. KARTINI, NO.11 021-8801954/88348492| 021-8824228 Y Y ALL COVERAGE
738 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
739 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
740 0410 RS. BELLA JL. IR. H. JUANDA, NO.141 BEKASI021-880 1775/ 880177/8819377021-
880177|021- 88017702188342438/88352506 Y Y ALL COVERAGE
741 0384 RS. MEKAR SARI JL. MEKAR SARI, NO.1021-8802641,8813787021-8813787|021-
8813787021-8810055/88350908 Y Y ALL COVERAGE
742 0250 KLINIK KARYA MEDIKA I JL. IR H JUANDA NO.38 C 021-8801293021-8800381|021-8800381 021-8816137 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
743 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
744 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
745 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
746 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
747 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
748 1013 RSIA SELASIH MEDIKA JL. RAYA BINTARA NO 5, BEKASI BARAT 021-8850155| 021-8844667 Y Y ALL COVERAGE
749 1038 KLINIK HARAPAN SEHAT III PERUMAHAN VILLA MUTIARA JAYA, BLOK MB 16/7, CIBITUNG 021- 68295994/88393875-|- - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
750 0947 RS. APRILIA MEDIKA JL. RAYA SETU NO.99 DESA LUBANG BUAYA, KEC SETU BEKASI 021 - 82611565/82603851|021-5901312 021 - 82611565 Y Y ALL COVERAGE
751 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
752 0950KLINIK HOSANA MEDICA MANGUN JAYA
(HOSANA MEDIKA IVJL. 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
753 0622 RSU. MITRA MEDIKAJL. DESA JATIWANGI-CIKEDOKAN/SEBELAH SELATAN KAWASAN MM 2100
KP KAMURANG RT 1/1 CIKEDOKAN, CIKARANG BARAT021-8998 3741/71691709/98213879| 021-89983575 Y Y ALL COVERAGE
754 0588 KLINIK MELVIANA JL. SAPARUA RAYA NO.239 - 240 PERUMNAS III BEKASI 082213067595; 021 - 8807610| 021-88341291 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
755 0036 RS. SENTOSA BEKASI ( Group Siloam ) JL. PAHLAWAN, NO.60 DUREN JAYA, BEKASI TIMUR 021-880 6140| 021-881 4950 Y Y ALL COVERAGE
756 0324 RS. GRAHA JUANDA JL. IR. H. JUANDA, NO.326021- 8811832, 8821004,
8811832,88346880|021- 8811832021 - 88346880 Y Y ALL COVERAGE
757 1140 RS. RAWA LUMBU JL. DASA DARMA, NO.20-23, RAWA LUMBU 021-82422511| 021-82432958 Y Y ALL COVERAGE
758 0960 RSB. MEKAR MULIAJL. KASUARI IV NO. 1-2, SEKTOR MEKAR ALAM, PASIMAL - CIKARANG
BARU021-8936940/66/|- 021-89830523 Y Y ALL COVERAGE
759 1334 RS. ANNA MEDIKA JL. RAYA PERJUANGAN NO 45, HARAPAN BARU, BEKASI UTARA 021 - 88882211| 021 - 88973042 Y Y ALL COVERAGE
760 0982 RS. BUDI LESTARI JL. KH.NOER ALIE, NO.2 DEPAN PERUMNAS II, KALIMALANG021-8842336/8893486021-8893486|021-
8893486021-8893487 Y Y ALL COVERAGE
761 0987 RB & KLINIK HARAPAN SEHAT CIBITUNG JL. TEUKU UMAR NO.33 CIBITUNG 021-88336674-|- 021-8901126 Y Y ALL COVERAGE
762 0988 RS. PERMATA BUNDA BEKASI PERUM GRAMAPURI TAMANSARI C1/8-10 CIBITUNG 021-88328001/88392537-|- 88328002 Y Y ALL COVERAGE
763 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
764 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
765 1216 RS. JUWITA JL. M. HASIBUAN NO.78 - BEKASI 021 -8829590/1| 021-8829592 Y Y ALL COVERAGE
766 1136 KLINIK PERMATA BUNDA BEKASI JL. BOSIH RAYA RUKO KARTIKA WANASARI BLOK.C1/4 CIBITUNG021- 88373158 / 021-88328001/
88392537|- N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
767 1090 RS. PERMATA CIBUBUR JL. ALTERNATIF CIBUBUR - CILEUNGSI NO.6A 021-8458806|- 021-84594263 Y Y ALL COVERAGE
768 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
769 1417 RSIA. RINOVA INTAN JL. RAYA SEROJA NO.101 021-8849401| 021-8848739 Y Y ALL COVERAGE
770 1203 KLINIK SEHAT SEJAHTERA I JL. NUSANTARA RAYA 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
771 1517 RSU. DR. ADAM TALIB JL. TEUKU UMAR, NO.25, CIBITUNG 021-88332305/06| 021-88332308 Y Y ALL COVERAGE
772 1277 RB & KLINIK GUCI MEDIKA JL. PRAMUKA NO.79 RAWA LUMBU 021-82433158| 021-8221921 Y Y ALL COVERAGE
BOGOR
773 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
774 1353 RS. CITAMA JL. RAYA PABUARAN NO.52 BOJONGGEDE 021-87985555| 021-87986666 Y Y ALL COVERAGE
775 1533 KLINIK DR.BETTY JL. RAYA NAROGONG, PERUMAHAN PT.SEMEN CIBINONG, CILEUNGSI 021-82493032| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
776 0133 RS. HERMINA BOGOR JL. RING ROAD-1, KAV.23,25,27, PERUM. TMN. YASMIN 0251-8382525| 0251-8328252 Y Y ALL COVERAGE
777 0755 RS. BINA HUSADA CIBINONG JL. MAYOR OKING NO.101, CIBINONG021-8758441; 87911000021- 8753422-
|021- 8753422-021-8752463 Y Y ALL COVERAGE
778 0720 RSIA. CITRA INSANI JL. RAYA PARUNG NO.242, LEBAKWANGI PEMAGARSARI, PARUNG0251 - 8611507/86177270251-
611507|0251-6115070251 - 8617493 Y Y ALL COVERAGE
779 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
780 1734 TELKOMEDIKA HEALTH CENTER (THC)BOGOR JL. PENGADILAN NO. 14 BOGOR 0251 - 8380134| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
781 1679 RS. ANNISA CITEUREUP JL. KARANGGAN NO 02 PUSPASARI CITEUREUP - BOGOR 021-8756780; 8752628| 021-8752628 Y Y ALL COVERAGE
782 1680 RSIA. SENTOSA JL. RAYA KEMANG NO 18 BOGOR 0251-7541900| 0251-7541900 Y Y ALL COVERAGE
783 0992 RS. BOGOR MEDICAL CENTER JL. PAJAJARAN INDAH V/97 BOGOR0251-
8307900/8390435/8346002/83797430251-0251-8313987/8353419 Y Y ALL COVERAGE
784 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
785 0673 RSU. MELANIA JL. RAYA PAHLAWAN NO.91 BONDONGAN - BOGOR0251- 8321196021-4506389|021-
45063890251-8331777 Y Y ALL COVERAGE
786 0190 RS. ISLAM BOGOR JL. PERDANA RAYA NO.22, BUDI AGUNG - KEDUNG BADAK 0251 - 8316822 / 7558159| 0251 -8347139 Y Y ALL COVERAGE
787 0835 RS. FAMILY MEDICAL CENTRE BOGOR JL. RAYA BOGOR KM.51 CIMANDALA-SUKARAJA (0251) 8652391| 0251-8661 605 Y Y ALL COVERAGE
788 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
789 0290 RS. MARY CILEUNGSI HIJAU JL. RAYA NAROGONG, KM.21, CILEUNGSI 021-82492222| 021-82493902 Y Y ALL COVERAGE
790 1103 RS. TRIMITRA CIBINONG JL. RAYA CIBINONG KM.43021-8763055-56021-8765993|021-
8765993021-8758038 Y Y ALL COVERAGE
791 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
792 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
Page 11 of 28
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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
793 6123 SILOAM HOSPITALS BOGOR JL. PAJAJARAN NO.27, BABAKAN, BOGOR TENGAH 0251-8303900| - Y Y ALL COVERAGE
794 2759 RS. KARYA BHAKTI PRATIWI JL. RAYA DRAMAGA KM. 7, DRAMAGA, BOGOR (0251) 8626868| (0251) 8626969 Y Y ALL COVERAGE
795 1251 KLINIK INSANI CIBINONG JL. MAYOR OKING JAYAATMAJA 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
796 3709 RS. VANIA JL. SILIWANGI NO.11 SUKASARI BOGOR TIMUR 0251-8380601/8380605| 0251-8380612 Y Y ALL COVERAGE
797 3000 RSUD. KOTA BOGOR JL. DR. SUMERU NO. 120 MENTENG, BOGOR BARAT 16111 0251-8312292| 0251-8371001 Y Y ALL COVERAGE
798 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
799 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
800 2116 RS. HERMINA MEKARSARI JL. RAYA CILEUNGSI - JONGGOL KM 1 KABUPATEN BOGOR 16820 021-29232525| 021-2923770 Y Y ALL COVERAGE
801 2393 RS. UMMI JL. EMPANG II NO.2 BOGOR RT.004/002 BOGOR SELATAN 0251-8341600| 0251-8341606 Y Y ALL COVERAGE
802 1385 RS. SENTRA MEDIKA CIBINONG JL. MAYOR OKING JAYA ATMAJA NO.9 CIBINONG021-87909999/87911212/(021)
80635969.|021-87909377 Y Y ALL COVERAGE
803 1662 RSIA. KENARI GRAHA MEDIKA GRIYA KENARI MAS BLOK B2 CILEUNGSI 021-8230426/82499885/96684076| 021-8231829 Y Y ALL COVERAGE
804 2191 RS. MEDIKA DRAMAGA JL. RAYA DRAMAGA KM. 7.3 MARGAJAYA BOGOR 0251- 8308900; 081319310610| 0251- 862577 Y Y ALL COVERAGE
805 1833 KLINIK PELITA SEHAT TAMAN KENARI RUKO PERUMAHAN TAMAN KENARI BLOK E3 NO 4, TANAH BARU BOGOR 0251-8664767| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
806 1831 KLINIK PELITA SEHAT CIBINONG CENTRAL RUKO CIBINONG BLOK B No 1-2 JL. MAYOR OKING No 63 021-87910241/08998513939| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
807 2718 KLINIK PELITA SEHAT CIOMAS JL. RAYA TAMAN PAGELARAN BLOK C1 NO.5, PADASUKA, CIOMAS, BOGOR (0251) 7522167| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
808 5813 KLINIK PRATAMA RAWAT INAP BUKAKAJL.RAYA NARONGONG BEKASI KM. 19,5 RT. 003 RW. 002 DESA LIMUS,
NUNGGAL, KEC. CILEUNGSI, KAB. BOGOR(021) 8231764| (021) 8231717 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
809 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
810 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
811 0389 RS. MH THAMRIN CILEUNGSI JL. RAYA NAROGONG, KM.16, LIMUS NUNGGAL, CILEUNGSI021-8235052 / 82491332021-
82491332|021-82491332021-82491331 Y Y ALL COVERAGE
812 4983 KLINIK GRACIA JL. RAYA NAROGONG KM. 17 (PANGKALAN 9) CILEUNGSI, (021) 82486305| (021) 82486305 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
813 3990 RSIA. BUNDA SURYATNI JL. KH. SOLEH ISKANDAR NO. 21, CIBADAK, TANAH SAREAL, BOGOR 16161 (0251) 754 3892/7543891| (0251) 754 3893 Y Y ALL COVERAGE
814 4694 RSB. PASUTRI JL. MERAK NO. 3 TANAH SAREAL, BOGOR (0251) 8349707| (0251) 8331938 Y Y ALL COVERAGE
815 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
816 0411 RS. AZRA JL. RAYA PAJAJARAN, NO.219 0251-8318456|- 0251-8331773/8324093 Y Y ALL COVERAGE
817 2955 RS. PERMATA JONGGOLJL. RAYA JONGGOL NO.1 A RT.008 RW.03, KEL.SUKAMANAH, JONGGOL,
BOGOR021 - 89931222/3| 021- 8993 1836 Y Y ALL COVERAGE
818 3420 RS. MULIA PAJAJARAN JL. RAYA PAJAJARAN NO. 98, BOGOR 0251-8379898 / 081288015174| 0251-8378800 Y Y ALL COVERAGE
819 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
820 2388 RS. PERTAMEDIKA SENTUL CITY JL. MH.THAMRIN KAV.57 SENTUL CITY 021-29672977/29672990| 021-29672978 Y Y ALL COVERAGE
821 2456 RSIA. JULIANA JL. RAYA TAJUR NO 75A - BOGOR 0251 - 8339593| 0251-8339591 Y Y ALL COVERAGE
822 2772 KLINIK SHIFA MEDIKA JL. BRANTA MULIA RT.002/07 KARANG ASEM TIMUR, CITEUREUP - BOGOR (021) 8760357| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
823 2809 KLINIK PERTAMEDIKA BOGOR JL. PANDAWA BLOK A-1 NO 14-15 BANTAR JATI II BUMI INDAH PRASTA I 0251-8363994| 0251-8363993 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
824 2788 RSIA. ASSALAM JL. RAYA BOGOR KM 46, NANGGEWER MEKAR, CIBINONG (021) 8753724| - Y Y ALL COVERAGE
825 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
826 2979 LAB. KLINIK KIMIA FARMA BOGOR JL. IR. H. JUANDA NO. 30, BOGOR 0251 - 8319030/8363473| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
827 1297 RB & KLINIK INSANI JL. PAHLAWAN NO.73B DESA KARANG ASEM TIMUR, CITEUREUP 021- 87942723/70247742| 021-87942570 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
828 1673 RB. PELITA SEHAT POMAD JL. RAYA CIBULUH RUKO NO 9 SIMPANG POMAD KEC BOGOR UTARA 0251-8658811| 0251-8652628; Y Y ALL COVERAGE
829 0468 RS. PMI BOGOR JL. RAYA PAJAJARAN, NO.80 0251-8324080-8393030-0817101934|- 0251-8382936/8324709 Y Y ALL COVERAGE
830 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
831 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
CIAMIS
832 1104 RS. PERMATA BUNDA CIAMIS JL. MR.IWA KUSUMASOMANTRI NO.10265-771650/7767450711-356173|0711-
3561730265-777658 Y Y ALL COVERAGE
833 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
CIANJUR
834 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
835 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
836 4107 RS. DR.HAFIZ JL. PRAMUKA NO. 15 SUKAMULYA, KARANG TENGAH, CIANJUR 0263-2910000| (0263) 2910010 Y Y ALL COVERAGE
CIKAMPEK
837 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
838 2472 RB & KLINIK NAURAH MEDIKA JL. A. YANI NO.02 RT.03 RW. 06 DS. CIKAMPEK SELATAN, CIKAMPEK (0264) 8389999| - Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
839 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
840 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
841 0540 RS. SARASWATI JL. JEND. A.YANI, NO.92, DAWUAN, CIKAMPEK-KARAWANG0264-311531/316101/ 311514/
3115270264-316391|0264-3163910264-311531 Y Y ALL COVERAGE
842 0375 RS. KARYA HUSADA JL. JEND. A.YANI, NO.98, CIKAMPEK-KARAWANG 0264-316188-89| 0264-312834/301626 Y Y ALL COVERAGE
843 1172 KLINIK PUTRA MEDIKA ( GROUP AQMA PUSAT ) JL. IR. H. JUANDA NO.14-19 SUKASEURI 0264-301652 / 8387129| 0264-8387129 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
844 1239 RUMAH SAKIT IZZA JL. KP.CISELAN DS.CIKAMPEK UTARA.KARAWANG 0264-319307/8386830-32| 0264-8386829 Y Y ALL COVERAGE
845 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
846 2445 RS. TITIAN BUNDA JL. IR. H. JUANDA NO.123 CIKAMPEK (0264) 8385999/8386222| (0264) 8388936 Y Y ALL COVERAGE
847 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
848 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
CIKARANG
849 1523 RSIA. NURUL ANNISAJL. RAYA CIKARANG CIBARUSA NO 88 DS. SUKARESMI CIKARANG
SELATAN, BEKASI021-897 4854/55| 021 - 8971122 Y Y ALL COVERAGE
850 0306 RS. ANNISA CIKARANG JL. RAYA CIKARANG BARU, NO.31, LEMAH ABANG, CIKARANG UTARA021-8904165/8901962/8904503021 -
8904503|021 - 8904503021-8903350/89113827 Y Y ALL COVERAGE
851 0385 RS. BHAKTI HUSADA JL. RE. MARTADINATA021-8900530/1021-890 0531|021-890
0531021-8900570 Y Y ALL COVERAGE
852 2087 KLINIK JB MEDICAL CENTER SHOP HOUSE PERMATA JUNCTION BLOK B A-15 JABABEKA 1 CIKARANG 021-89846023/24| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
853 2034 RSIA. CIKARANG MEDIKA JL. KH. FUHDOLI NO.78 KAMPUNG KAUM CIKARANG UTARA, BEKASI 021-8902210| 021-82607637 Y Y ALL COVERAGE
854 1962 KLINIK & APOTEK KEMALA JL. TARUM BARAT 2, RUKO GRAND ARTHA NIAGA 2 BLOK O2 NO. 23 - 23A 021-29083377 - 29083376| 021- N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
855 0574 KLINIK BUDI LUHURJL. RAYA IMAM BONJOL, NO.74, RT.07/04, DESA SUKADANAU,CIKARANG
BARAT021- 88327226/88320116| 021-88327226 Y Y ALL COVERAGE
856 1795 KLINIK KHANZA MEDIKA PERUM KOTA SERANG BARU BLOK B 72 NO 25-26, CIKARANG 021-89953361/081212565880| 021-89953117 Y Y ALL COVERAGE
857 2454 RS. HOSANA MEDIKA CIKARANG BARU JL. ANGGREK I B2/2 RT.01/11 DS. MEKARMUKTI - CIKARANG (021) 89831626; 89835418; 89835223| 021-89830442 Y Y ALL COVERAGE
858 2510 MITRASANA TAMAN ASTER RUKO TAMAN ASTER KAV. A3 NO. 41 TELAGA ASIH CIKARANG BARAT 88333364| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
859 0263 RB & KLINIK YAYASAN BINA MEDIKA KP. KONGSI, CIKARANG 021-8900050; 021-8900051|021-8900051 021-8900051 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
860 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
861 0738 RS. AMANDA CIKARANG SELATAN JL. RAYA SERANG NO.83 CIKARANG SELATAN021-8971643021-89110011|021-
89110011021-8970808 Y Y ALL COVERAGE
862 0660RS. PERMATA KELUARGA LIPPO CIKARANG d/h
RS HarapanJL. MH.THAMRIN KAVLING 129 LIPPO CIKARANG 021-8990 5588/ 8990 1927| 02189901860/89901902 Y Y ALL COVERAGE
863 1041RS HARAPAN KELUARGA (d/h RS.HARAPAN
INTERNASIONAL)JL.KASUARI RAYA KAV.1A-1B, KOTA JABABEKA, CIKARANG BARU 021-89840745|- 021-89835839 Y Y ALL COVERAGE
864 0850KLINIK BERKAT MELIMPAH JABABEKA (HOSANA
MEDIKA II)JL. KAWASAN INDUSTRI I, JABABEKA B8, CIKARANG UTARA 021-8937941021-8937942|021-8937942 021-8937942,89833055 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
865 1050 RS. AMANDA CIKARANG UTARA JL. RAYA INDUSTRI NO.36,CIKARANG UTARA 021- 8900277 / 89110011|021-8900277 021-89110011 Y Y ALL COVERAGE
866 0913 RS. ASRI MEDIKA JL. CITANDUY RAYA BLOK L II NO.1 CIKARANG UTARA 021-89142968, 89142969-|- 02189143860/89143036 Y Y ALL COVERAGE
Page 12 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
867 0929 KLINIK RENNICHA PUTRA JL. RAYA CIKARANG CIBARUSAH NO 89 LIPPO CIKARANG 021-8971852021-8971658|021-8971658 021-8971852 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
868 0966 RB & KLINIK CENTRAL MEDIKA JL. PILAR - SUKATANI, DS SUKARAYA NO 84, KARANG BAHAGIA 021- 89111103-|- 021-89119714 N YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
869 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
870 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
871 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
872 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
873 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
874 1067 RS. MEDIROSSA JL. INDUSTRI TEGAL GEDE - CIKARANG SELATAN 021-89833216| 021-8934979 Y Y ALL COVERAGE
875 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
876 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
877 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
878 0275 RS. SENTRA MEDIKA CIKARANG JL. RAYA INDUSTRI PASIR GOMBONG JABABEKA, CIKARANG021 8904160-64 / EXT
225/081297102702|021-8904159,89111112 Y Y ALL COVERAGE
879 0916 RB & KLINIK GRAHA BINA HUSADA JL. INDUSTRI SELATAN NO.1A, BLOK NN 3A, INDUSTRI JABABEKA II 021-89836243-|- 021-89836244 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
880 1842 RS. MEDIROSSA 2 JL. RAYA CIBARUSAH DESA SINDANGMULYA KEC. CIBARUSAH BEKASI 021-89955555| 021-89952355 Y Y ALL COVERAGE
881 1462 RS. MITRA KELUARGA CIKARANG JL. INDUSTRI RAYA, NO.100 LEMAH ABANG, CIKARANG 021-89840500/89840900| 021-89845489 Y Y ALL COVERAGE
882 6474 KLINIK ALFARMA KP.KAUM LEBAK NO.101 RT 04/02 SIMPANGAN, CIKARANG UTARA (021) 89323270| (021) 8905376 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
883 1719 CMC CLINIC ( CIKARANG MEDICAL CENTER )SHOPHOUSE BLOK A NO.14-15, 28-29 JABABEKA I KAWASAN INDUSTRI
CIKARANG021-8934371| 021-8934035 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
884 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
885 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
886 1308 RS. RIDHOKA SALMA JL. IMAM BONJOL NO.7 GARDU SAWAH 021-89116527| 021-89116528 Y Y ALL COVERAGE
887 2742 KLINIK SUMBER SEHAT CIKARANGJL. KH. FUDHOLI NO.50 RT.01/04 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
888 1287 RB & KLINIK NIZA ASYIFA BERSAMA 1 PERUMAHAN TELAGA HARAPAN BLOK E1 NO.1 CIKARANG BARAT 021-89109638| 021-89109638 Y YGP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
889 4032 RB & KLINIK RIA PILAR JL. GATOT SUBROTO NO. 67(021) 89105057 / 087717188000 /
085669228852|(021) 8900487 Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
890 5118KLINIK 24 JAM & HARAPAN SEHAT MEGA
REGENCYJL. RAYA MEGA REGENCY PERUM MEGA REGENCY BLOK I NO 3 021-29370936| 021-883366721 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
891 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
892 2462KLINIK 24 JAM & RB. PERMATA BUNDA
CIKARANGRUKO GRAMA NIAGA H2 NO. 15/15A, KARANG ASIH - CIKARANG UTARA 021 - 2928 2165, 021 - 2928 2166| - Y Y
GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
893 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
894 0709 RS. HOSANA MEDICA LIPPO JL. UTAMA BIIE NO 01 LIPPO CIKARANG 021-8972472| 021-89900769 Y Y ALL COVERAGE
895 0391 SILOAM HOSPITALS LIPPO CIKARANG JL. MH. THAMRIN, KAV.105, LIPPO CIKARANG 021- 29636900| 021-89900022/8972470 Y Y ALL COVERAGE
896 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
897 1824 KLINIK BUNDA AULIA JL. HAJI RATIM NO. 143 DS JATIWANGI CIKARANG BARAT - BEKASI 021-8998 3742 / 2897 3209| 021-8998 3742 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
898 2061 RS. BUDI ASIH CIKARANGJL. RAYA SERANG - CIBARUSAH RT 01/ RW 01 SERANG KEC.CIKARANG
SELATAN,BEKASI021 - 89677795| 021-89677402 Y Y ALL COVERAGE
899 1494 RB & KLINIK ANNISA IV JL. RAYA CIBARUSAH NO.63 SERANG BARU 021-89954434| 021-89954434 Y Y ALL COVERAGE
CIMAHI
900 0268 RS. MITRA KASIH JL. RAYA CIBABAT NO.341, CIMAHI 022-6654852,6652774,6654397| 022-6654875/6642349 Y Y ALL COVERAGE
901 2467 RSU. KASIH BUNDA JL. MAHAR MARTANEGARA NO.166 LEUWIGAJAH - CIMAHI 40521 022- 6614221/ 6630585| 022- 6630583 Y Y ALL COVERAGE
902 2221 RS. AVISENA CIMAHI JL. MELONGASIH NO. 170 CIJERAH - CIMAHI 022 - 6000830| 022-6000830 Y Y ALL COVERAGE
903 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
904 5610 RSAD. TK II DUSTIRA JL DUSTIRA NO. 1 BAROS, KOTA CIMAHI 022-6652207| - Y Y ALL COVERAGE
CIREBON
905 5784 RSUD. GUNUNG JATI JL. KESAMBI NO. 56, KOTA CIREBON 0231-206330| - Y Y ALL COVERAGE
906 1174 RS. SUMBER KASIH JL. SILIWANGI NO.135 0231-203815| 0231-210040 Y Y ALL COVERAGE
907 1091 RS. PUTERA BAHAGIA JL. CIREMAI RAYA NO.114 ,PERUMNAS0231-207351, 4856540231-485654|0231-
4856540231-486356/482328 Y Y ALL COVERAGE
908 1029 RS. SUMBER WARAS CIWARINGIN JL. URIP SUMOHARJO, NO.5, CIWARINGIN 0231-342297/341079,3300888,341079-|- 0231-342112 Y Y ALL COVERAGE
909 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
910 2690 KIMIA FARMA 40 (BM CIREBON) JL. PARUJAKAN NO.12 , 0231-208954| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
911 4677 RS. PERMATA CIREBON JL. TUPAREV NO. 117 KEDAWUNG, KAB. CIREBON (0231) 883 8877; 833 8899| 0231-8293698 Y Y ALL COVERAGE
912 0602 RS. PERTAMINA CIREBON JL. PATRA RAYA, KLAYAN0231-224646; 25121730231-
224646|0231-2246460231-224795; 209328 Y Y ALL COVERAGE
913 1316 RS. MITRA PLUMBON JL. RAYA PLUMBON, KM.11 0231-324483/323100| 0231-322355/322066 Y Y ALL COVERAGE
914 0293 RS. PELABUHAN CIREBON JL. SISINGAMANGARAJA, NO.450231-208948/208680 / 0231-2056570231-
205657|0231-2056570231-234670 Y Y ALL COVERAGE
915 2378 RS. KHUSUS JANTUNG HASNA MEDIKA JL. RD GILAP NO. 8 PALIMANAN TIMUR, KABUPATEN CIREBON 0231-343405; 343645| 0231-342224 Y Y ALL COVERAGE
916 2422 RSIA. KHALISAH JL. DR. SETIABUDI NO. 8 PEGAGAN PALIMANAN CIREBON 0231-342440/342441| 0231-343362 Y Y ALL COVERAGE
917 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
918 3882 RSIA. CAHAYA BUNDA JL. RAYA PERJUANGAN NO.8 KESAMBI CIREBON 0231-8333388 / 99| 0231-482121 Y Y ALL COVERAGE
DEPOK
919 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
920 1194 RS. HASANAH GRAHA AFIAH JL. RADEN SALEH NO.42 DEPOK 021-77826267/ 77826276| 021-77833796 Y Y ALL COVERAGE
921 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
922 1737 TELKOMEDIKA HEALTH CENTER (THC) DEPOK JL. RAYA KARTINI NO. 17RT. 02 RW.09 DEPOK PANCORAN MAS 021-77219925| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
923 0346 RS. TUGU IBU JL. RAYA BOGOR, KM.29, CIMANGGIS - DEPOK021-8710870/021-8718634/33|021-
8718634/33021-8708266 Y Y ALL COVERAGE
924 6453 RSIA. CITRA ARAFIQ JL. PERINDUSTRIAN RT/RW:006/025, KEL.BAKTIJAYA, KEC.SUKMAJAYA 021-87708400| 021-87708400 Y Y ALL COVERAGE
925 2722 RS. PERMATA DEPOK JL. RAYA MUCHTAR NO. 22 SAWANGAN DEPOK 021-29669000| 021-29668897 Y Y ALL COVERAGE
926 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
927 0777 RSIA. TUMBUH KEMBANG JL. RAYA BOGOR, KM.31, NO.23, CIMANGGIS021-8701873-74 / 021-8712300|021-
8712300021-8701872 Y Y ALL COVERAGE
928 0107 RS. SIMPANGAN DEPOK JL. RAYA BOGOR, KM.36, SIDAMUKTI SUKMAJAYA, CIMANGGIS - DEPOK 021-8741549| 021-8741574 Y Y ALL COVERAGE
929 1485 RS. MITRA KELUARGA DEPOK JL. MARGONDA RAYA, PANCORAN MAS - DEPOK 021-77210700| 021-77212155 Y Y ALL COVERAGE
930 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
931 2760 RS. CITRA MEDIKA DEPOK JL. RAYA KALI MULYA NO.68 KOTA KEMBANG, CILODONG 021-29671000/5000/7000/8000| 021-29678000 Y Y ALL COVERAGE
932 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
933 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
Page 13 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
934 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
935 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
936 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
937 1056 RS. BUNDA MARGONDA JL. MARGONDA RAYA NO.28 PONDOK CINA-DEPOK 16424 021-78890551|- 021-78889958 Y Y ALL COVERAGE
938 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
939 2090 KLINIK QITA JL. SEDAP MALAM RAYA NO. 5 KOMP. PERTANIAN DEPOK, CITAYAM 021-87989096| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
940 2078 APOTIK FARMARIN V DEPOKJL. ARIF RAHMAN HAKIM SIMPANG 3 MARGONDA NO. 7 KEL DEPOK, KEC
PANCORAN MAS DEPOK021-7757117| 021-29402214 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
941 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
942 1736 KJP MEDICAL CENTER JL. KEJAYAAN BLOK IX NO 4 SUKMAJAYA, DEPOK TIMUR 021-7703925, 7714605| 021-7703927 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
943 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
944 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
945 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
946 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
947 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
948 2460 KLINIK UTAMA TUGU SAWANGAN JL. RAYA MUCHTAR NO. 20 RT.002/007 SAWANGAN - DEPOK 16511 0251-8613433/021-29420173| 0251-8613433 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
949 0776 RS. PURI CINERE JL. MARIBAYA BLOK F2, NO.10, PURI CINERE - DEPOK 021-7545488| 021-7545486 Y Y ALL COVERAGE
950 0470 RS. SENTRA MEDIKA DEPOK JL. RAYA BOGOR KM.33 CISALAK - DEPOK 021-874 3790| 0218743230/87741666 Y Y ALL COVERAGE
951 1007 RS. HARAPAN DEPOK JL. PEMUDA NO.10 021-7520009,7773817,77200005-|- 021-7765883 Y Y ALL COVERAGE
952 0009 RSU. BHAKTI YUDHA JL. RAYA SAWANGAN NO.24, DEPOK 021-7520082| 021-7775862/7762880 Y Y ALL COVERAGE
953 1615 RSIA. ASYIFA DEPOK JL. CINERE DEPOK NO 9 RANGKAPAN JAYA BARU PANCORAN MAS, DEPOK 021-77883905/77885454| 021-77885454 Y Y ALL COVERAGE
954 0265 RS. HERMINA DEPOK JL. RAYA SILIWANGI, NO.50, PANCORAN MAS 021-77202525| 021-7763309 Y Y ALL COVERAGE
955 1085 RS. MEILIA JL. ALTERNATIF CIBUBUR KM.1 CIMANGGIS DEPOK 021-8444444,84598954-|- 021-84598952 Y Y ALL COVERAGE
956 1098 RS. GRHA PERMATA IBU JL. KH. M. USMAN NO.168 KUKUSAN BEJI 021-7778899-|- 021-7778998 Y Y ALL COVERAGE
957 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
GARUT
958 2358 KLINIK MAHESA JL. CIMANUK NO.8 0262-233238| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
959 4039 RS. NURHAYATI JL. SUDIRMAN NO. 6 GARUT 0262-238966| 0262-231824 Y Y ALL COVERAGE
960 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
961 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
962 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
963 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
964 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
INDRAMAYU
965 4126 LAB. PRODIA INDRAMAYU JL. RAYA PAKANDANGAN ( DEPAN GRIYA ASRI I ) BUNDERAN MANGGA 0234-275065| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
KARAWANG
966 5434 KLINIK AR-RAHMAN JL. RAYA PERURI NO. 07, TELUK JAMBE TIMUR, KARAWANG (0267) 8458155| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
967 2731 RS. ROSELAJL. INTERCHANGE TOL KARAWANG BARAT NO.3 DS WADAS KEC. TELUK
JAMBE(0267) 8637207/8637205| 0267 8367205 Y Y ALL COVERAGE
968 1006RS. CITRA SARI HUSADA (D/H KLINIK INTAN
BAROKAH)JL. RAYA KOSAMBI-TELAGASARI, KM.3, KLARI, KARAWANG TIMUR 0267-437507/8617972| 0267-438681 Y Y ALL COVERAGE
969 1022 RSU. FIKRI MEDIKA JL. RAYA KOSAMBI- TELAGASARI, DS BLENDUNG , KLARI0267-433636/435527 - 0267-
8615555/8615566 (KLINIK):|-0267-8615577/88 Y Y ALL COVERAGE
970 1409 RSU. PURI ASIH JATISARI JL. RAYA JATISARI NO.3 PASAR JATISARI 0264-361459/361466| 0264-8375276 Y Y ALL COVERAGE
971 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
972 4699 RSIA. SENTUL CIKAMPEK JL. A. YANI NO.16 SENTUL, CIKAMPEK SELATAN (0264) 8386671/ 8389060| (0264) 316096 Y Y ALL COVERAGE
973 1133 RS. MANDAYA(D/H RS.CITO KARAWANG) JL. ARTERI TOL KARAWANG BARAT TELUK JAMBE0267-8643000/8641414/414245 / 414264
/ 8643002|0267-414306 Y Y ALL COVERAGE
974 6017 KLINIK LAMARANJL. SYECH QURO NO. 4 KEL. PALUMBONSARI KEC. KARAWANG TIMUR KAB.
KARAWANG 413510267-8453951| 0267-8453951 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
975 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
976 4683 KLINIK SEHAT BAHAGIA JL. PANATAYUDHA I NO. 57 A RT. 02 RW. 03 NAGASARI, KARAWANG (0267) 414 283| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
977 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
978 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
979 2823 RS. LIRA MEDIKA JL. SYECH QURO NO.14 LAMARAN, KARAWANG - JAWA BARAT (0267) 8452555 / 405 752| (0267) 405 752 Y Y ALL COVERAGE
980 0255 RS. BAYUKARTA JL. KERTABUMI, NO.440267-401817/401818/4003510267-
801818|0267-8018180267-404472/401202 Y Y ALL COVERAGE
981 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
982 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
983 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
984 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
985 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
986 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
987 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
988 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
989 0083 RS. DEWI SRI JL. ARIF RAHMAN HAKIM, NO.10267-401475, 402855, 406445,
402147|0267-4021470267-404010 Y Y ALL COVERAGE
990 1635 KLINIK MITRA KONDANG UTAMA JL. PENGAIRAN CITRA KEBUN MAS KONDANG KARAWANG 0267-8402700/0267-8616923| 0267-8450001 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
991 2741 RSIA. MITRA FAMILY-KARAWANGJL. RONGGOWALUYO RT.02/05 DESA SUKAHARJA KEC. TELUKJAMBE
TIMUR, KARAWANG0267 - 8458327 , 8458328, 8458329| - Y Y ALL COVERAGE
992 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
993 0691 KLINIK PURWA MEDIKA JL. RAYA TAMELANG NO.12 DESA MEKARJAYA, PURWASARI 0267-433653| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
994 0689 KLINIK MITRA SEHAT JL. KOSAMBI - CURUG NO.28, DUREN, KLARI 0267-8402061/433930| 0267-8402061 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
995 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
996 0197 KLINIK GEMPOL JL. RANGGA GEDE NO.29, GEMPOL, TANJUNG PURA 0267-412117/8453903| 0267-8453903 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
997 0869 RS. DELIMA ASIH SISMA MEDIKA JL. WIRASABA NO.54 JOHAR 0267-403073/8454248|- 0267-405598 Y Y ALL COVERAGE
998 1023 RS. ISLAM KARAWANG JL. PANGKAL PERJUANGAN KM.20267-414520, 0267 - 414524,
4145210267-414524|0267-4145240267-413277 Y Y ALL COVERAGE
999 1027 KLINIK BINA MEDIKA KARAWANG JL. RAYA TELUK JAMBE NO 8, SUKA GALIH, TELUK JAMBE TIMUR 0267-641968 / 08121918055-412117|- 0267 - 641968 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1000 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
1001 0095 KLINIK GRAHA MEDIS JL. RAYA KOSAMBI, NO.23, DUREN KLARI, KARAWANG TIMUR 0267-435527| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1002 1058 KLINIK NAFILA MEDIKA JL. PRINGGODANI BLOK J-47 PERUMNAS TELUK JAMBE, KARAWANG BARAT 0267-640020|- 0267-8456419 N Y ALL COVERAGE
1003 1059 KLINIK PURI ASIH TELUKJAMBE JL. PERURI NO. 99 PINAYUNGAN, TELUK JAMBE, KARAWANG TIMUR 0267-646845|- 0267-646845 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1004 1314 RSIA. DR. DJOKO PRAMONO JL. PANATAYUDA 1, NO.35, KARAWANG BARAT 0267-403009/418818/403744| 0267-411744/8454710 Y Y ALL COVERAGE
Page 14 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
KUNINGAN
1005 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
1006 1704 RS. SEKAR KAMULYAN JL. RUMAH SAKIT NO 28, CIGUGUR KUNINGAN 0232-873206| 0232-875516 Y Y ALL COVERAGE
1007 1345 RS. JUANDA KUNINGAN JL. IR. H. JUANDA NO.207 KUNINGAN 0232-876433/875871| 0232-876433/875871 Y Y ALL COVERAGE
MAJALENGKA
1008 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
1009 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
1010 1526 RS. AMIRA JL. IPIK GANDAMANAH RT.035 RW.003 MUNJUL JAYA 0264-8221191/92| 0264-8221193/95 Y Y ALL COVERAGE
1011 5986 KLINIK ANNISAJL. RAYA INDUSTRI KP. MARACANG RT. 07/02 DESA MARACANG KEC.
BABAKANCIKAO, PURWAKARTA(0264) 822 2596| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1012 5987 KLINIK ANNISA 2 JL. PRAMUKA NO. 107 DESA BUNDER KEC. JATILUHUR PURWAKARTA (0264) 822 0201| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1013 1718 RS. KHUSUS BEDAH RAMA HADI JL. RAYA SADANG - SUBANG , DS CIWANGI BUNGUR SARI PURWAKARTA 0264 - 202136 / 8282295| 0264-8225679 Y Y ALL COVERAGE
1014 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
1015 4044 RSU. HOLISTIC PURWAKARTA JL. TERUSAN KAPTEN HALIM KM.09 SALAMULYA, PONDOK SALAM 0264-8223434 / 0811129434| 0264-8223432 Y Y ALL COVERAGE
1016 4443 KLINIK MITRA MEDIKA PURWAKARTA JL. MR. DR. KUSUMAATMAJA NO. 13, KEL. CIPAISAN, PURWAKARTA (0264) 8624195| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1017 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
1018 1545 RS. MH THAMRIN PURWAKARTA JL. BUNGURSARI, NO.36 0264-8222222| 0264-8222223 Y Y ALL COVERAGE
1019 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
1020 1057 RSIA. ASRI PURWAKARTA JL. VETERAN CIHIDEUNG NO.15 PURWAKARTA 0264-211680; 8223161; 0811117031|- 0264-219047 Y Y ALL COVERAGE
1021 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
1022 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
1023 1043 SILOAM HOSPITAL PURWAKARTA JL. BUNGURSARI NO.1 PO.BOX 167 - Purwakarta 0264-8628900/8628911|0264-231273 0264-212674 Y Y ALL COVERAGE
1024 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
1025 1620 RS. BHAKTI HUSADA II PURWAKARTAJL. RAYA SADANG SUBANG, KM 5, KP. KIARA DUA, DS. CIKUMPAY, KEC.
CAMPAKA0264-8225344/8225345/081373360783| 0264-8225255 Y Y ALL COVERAGE
1026 4054RS. KARINA MEDIKA PURWAKARTA D/H
MASITHOHKP.KRAJAN RT. 01/01 MARACANG, BABAKAN CIKAO (0264) 8220544| (0264) 8623240 Y Y ALL COVERAGE
SUBANG
1027 2752 KLINIK MITRA ABADI JL. KAPTEN HANAFIAH NO.3 RT. 98 RW. 27 KEL. KARANGANYAR, SUBANG 0260-418247| 0260-418237 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1028 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
1029 0191 RS. PERKEBUNAN NUSANTARA 8 SUBANG JL. OTTO ISKANDAR, NO.1, SUBANG0260-
420406,411632,420306,420436|0260-0260-420391 Y Y ALL COVERAGE
SUKABUMI
1030 1506RS. KARTIKA KASIH (D/H RS.KARTIKA MEDICAL
CENTER)JL. JEND. A.YANI, NO.18 0266-6250902/6250905/6250904| 0266-6250901 Y Y ALL COVERAGE
1031 3448 RS. RIDOGALIH JL. GUDANG NO. 24 SUKABUMI 0266-221983| 0266-216161 Y Y ALL COVERAGE
1032 0056 RS. ISLAM ASSYIFA JL. JEND. SUDIRMAN, NO. 270266-
222663/218672/241463/223742/22374200266 - 213433/22350 Y Y ALL COVERAGE
1033 0832 RS. HERMINA SUKABUMI JL. RAYA SUKARAJA RT.003/03, SUKARAJA 0266-6252525/6249292| 0266-235020 Y Y ALL COVERAGE
1034 6016 KLINIK PERMATA SUKABUMI JL. RA. KOSASIH NO.112 RT.02/16 CISARUA, CIKOLE (0266) 219188/6245414| (0266) 6247781 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1035 1507 RS. BHAKTI MEDICARE JL. RAYA SILIWANGI, CICURUG 0266-731555| 0266-731899 Y Y ALL COVERAGE
1036 2892 RS. KARTIKA CIBADAK JL. SILIWANGI NO.139, CIBADAK, SUKABUMI (0266) 7160071| (0266) 535586 Y Y ALL COVERAGE
1037 1107 RS. BETHA MEDIKA JL. RAYA CISAAT NO.595 SUKABUMI 0266-216422,224128-|- - Y Y ALL COVERAGE
SUMEDANG
1038 2122 KLINIK PADJADJARAN JATINANGORJL. KOLONEL AHMAD SYAM RT 04 RW 02 DESA SAYANG KEC. JATINANGOR -
BANDUNG022 -7781900| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1039 1128 RS. PAKUWON SUMEDANG JL. RD.DEWI SARTIKA NO.17 SUMEDANG 45311 0261-210834/2797773/201132| 0261-210834 Y Y ALL COVERAGE
1040 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
1041 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
1042 4798 RSIA. BUNDA AISYAH JL. R. E. MARTADINATA NO. 200B TASIKMALAYA (0265) 7297400; 7297401| - Y Y ALL COVERAGE
1043 3203 RSIA. UMMI TASIKMALAYA JL. PASEH NO.10 - TASIKMALAYA 0265-329126| - Y Y ALL COVERAGE
1044 0253 RS. JASA KARTINI JL. OTTO ISKANDARDINATA NO 15 0265-331808/331641;|0265-3318641 0265-331808/331114 Y Y ALL COVERAGE
1045 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
1046 1625 RS. TASIK MEDIKA CITRATAMA (TMC) JL. HZ MUSTOFA NO 310 TASIKMALAYA 0265-322333| 0265-326767 Y Y ALL COVERAGE
1047 2773 RSB. SAYANG BUNDA JL. N. SUKALAYA I NO.22 0265330841| 0265-330841 Y Y ALL COVERAGE
1048 2390 RS. PRASETYA BUNDA TASIKMALAYA JL. IR. H. JUANDA NO. 1 (SIMPANG JATI) 0265344477/0265320100/| - Y Y ALL COVERAGE
1049 2466 RS. PERMATA BUNDA TASIKMALAYA JL. BRIGJEND HR. WASITA KUSUSMAH NO.1 TASIKMALAYA, JAWA BARAT 0265-345650| - Y Y ALL COVERAGE
1050 0256 RSI. HJ. SITI MUNIROH TASIKMALAYA JL. TAMAN SARI, GOBRAS, NO.208 0265-323868,327630|0265-327630 0265-327630 Y Y ALL COVERAGE
1051 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
JAWA TENGAH
BANYUMAS
1052 3171 RSU. WIRADADI HUSADA JL. MENTERI SUPENO NO. 25 SOKARAJA BANYUMAS 0281-6846225| 0281-6846371 Y Y ALL COVERAGE
BATANG
1053 3360 RS. QOLBU INSAN MULYA (QIM) JL. URIP SUMOHARDJO SAMBONG-BATANG, JAWA TENGAH 0285-4495222| 0285-4495224 Y Y ALL COVERAGE
BOYOLALI
1054 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
1055 1661 RS. PKU AISYIYAH BOYOLALI JL. PASAR SAPI BARU SINGKIL 0276-322898/3293400| 0726-3293400 Y Y ALL COVERAGE
BREBES
1056 2292 RS. BHAKTI ASIH BREBES JL. PANGERAN DIPONEGORO NO 125 PESANTUNAN, BREBES 0283-673481/671279| 0283-671391 Y Y ALL COVERAGE
1057 1664 RS. DEDY JAYA JL. A. YANI NO 57 BREBES 0283-672145| 0283-672525 Y Y ALL COVERAGE
1058 4057 RS. DERA AS-SYIFA JL. MERDEKA NO. 191, BANJARHARJO, BREBES (0283) 889588| (0283) 889583 Y Y ALL COVERAGE
BUMIAYU
1059 3173 RSU. ALLAM MEDICA BUMIAYU JL. DIPONEGORO NO. 609, JATISAWIT BUMIAYU 0289-430822| - Y Y ALL COVERAGE
1060 1889 RS. MUHAMMADIYAH SITI AMINAH JL. DIPONEGORO, BUMIAYU 0289-432209/430683| 0289-430683 Y Y ALL COVERAGE
CEPU
1061 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
1062 1438 RS. MUHAMMADIYAH CEPU JL. RONGOLAWE, NO.137 0296-421727| 0296424678/424569 Y Y ALL COVERAGE
CILACAP
1063 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
1064 0975 RS. ISLAM FATIMAH CILACAP JL. H JUANDA NO.20 0282-542396|- 0282-541065/5452151 Y Y ALL COVERAGE
1065 2866 RSUD. CILACAP JL. JEND GATOT SUBROTO NO. 28 CILACAP 0282-533010| 0282-520755 Y Y ALL COVERAGE
1066 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
1067 4165 RS. APRILLIA JL. JEND GATOT SUBROTO NO.95 CILACAP 0282-536307| 0282-521144 Y Y ALL COVERAGE
Page 15 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1068 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
1069 1152 RS. SANTA MARIA CILACAP JL. JEND.A.YANI NO.38 CILACAP (0282) 534859, 521725| (0282) 531296 Y Y ALL COVERAGE
1070 3278 LAB. PRODIA CILACAP JL. S. PARMAN NO. 33 CILACAP 0282-5253314| - N Y GP,LAB
DEMAK
1071 2205 RSU. PELITA ANUGERAH JL. RAYA BANDUNG REJO KM 11.5 (SMG-PURWODADI) 024-6725555| 024-6725550 Y Y ALL COVERAGE
GOMBONG
1072 3327 RS. PKU MUHAMMADIYAH GOMBONG JL. YOS SUDARSO NO.461,GOMBONG 0287-471780| - Y Y ALL COVERAGE
1073 1243 RS. PALANG BIRU JL. KARTINI, NO.37 0287-471290/471762| 0287-473221/471762 Y Y ALL COVERAGE
JEPARA
1074 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
1075 3368 RSUD. KARTINI JEPARA JL. KH. WAHID HASYIM NO. 175 BAPANGAN, JEPARA, JAWA TENGAH 0291-598180/591175| 0291-591145 Y Y ALL COVERAGE
KENDAL
1076 1666 RSI. MUHAMMADIYAH KENDAL JL. AR RAHMAH NO 17 WELERI 0294-641870 / 0294-643756| 0294-644150 Y Y ALL COVERAGE
KLATEN
1077 0754 RS. ISLAM KLATEN JL. RAYA SOLO KM.4 0272-322252|- 0272-332422 Y Y ALL COVERAGE
1078 1519 RSU. PKU MUHAMMADIYAH DELANGGU JL. DELANGGU UTARA, NO.19 0272-551051| 0272-554041 Y Y ALL COVERAGE
1079 1441 RS. CAKRA HUSADA KLATEN JL. MERBABU, NO.7 0272-321123-322386-322394| 0272-329029 Y Y ALL COVERAGE
1080 3273 LAB. PRODIA KLATEN JL. PEMUDA SELATAN NO. 85 KLATEN 081931783130| - N Y GP,LAB
KUDUS
1081 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
1082 0146 RS. MARDI RAHAYU KUDUS JL. AKBP.R. AGIL KUSUMADYA, NO.110 0291-434707-12/435582/443581| 0291-438398,434711 Y Y ALL COVERAGE
1083 3259 LAB. CITO (JL. AKBP AGIL KUSUMADYA NO. 7 ) JL. AKBP AGIL KUSUMADYA NO. 7 0291-4251979| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
MAGELANG
1084 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
1085 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
1086 1165 RSIA. GLADIOOL JL. KENANGA, NO.4-6 0293-362702| - Y Y ALL COVERAGE
1087 0335 RS. HARAPAN MAGELANG JL. P. SENOPATI, NO.11 0293-364033-35| 0293-364036-37 Y Y ALL COVERAGE
1088 1132 RS. LESTARI RAHARJA JL. MAYJEN SUTOPO NO.5 0293-362225| 0293-362649/311512 Y Y ALL COVERAGE
PATI
1089 1534 RS. MITRA BANGSA JL. KOLONEL SUGIYONO, NO.75 PATI 0295-382555| 0295-4191994 Y Y ALL COVERAGE
1090 1299 KELUARGA SEHAT HOSPITAL JL. P.SUDIRMAN NO.9 MARGOREJO 0295-386111| 0295-384422 Y Y ALL COVERAGE
1091 4455 RSU FASTABIQ SEHAT JL. RAYA PATI - TAYU KM.3 TAMBAHARJO, PATI, JAWA TENGAH (0295) 4199008| - Y Y ALL COVERAGE
PEKALONGAN
1092 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
1093 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
1094 5665 RSU. H.A DJUNAIDJL.PELITA II RT.05/RW.02, BUARAN KRADENAN KEL. BUARAN KRADENAN
KEC. PEKALONGAN SELATAN(0285) 436325/ 4410660| (0285) 436326 Y Y ALL COVERAGE
1095 1220 RS. BUDI RAHAYU PEKALONGAN JL. BARITO, NO.5 PEKALONGAN 0285 - 423491/424340| 0285-423002 Y Y ALL COVERAGE
1096 0120 RS. SITI KHODIJAH PEKALONGAN JL. BANDUNG, NO.39-47 KOTA PEKALONGAN 0285-422845,425138,423590,424919| 0285-425138 Y Y ALL COVERAGE
PEMALANG
1097 4093 RS. PRIMA MEDIKA PEMALANG JL. SLAMET RIYADI NO. 321 MULYOHARJO 0284 - 324221 / 322448| - Y Y ALL COVERAGE
1098 1219 RSU. SANTA MARIA PEMALANG JL. PEMUDA NO.24 0284 - 321251/321426| 0284 - 322335 Y Y ALL COVERAGE
PURBALINGGA
1099 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
1100 1888 RSU. HARAPAN IBU PURBALINGGA JL. MAYJEND SOENGKONO NO. 1 0281-892222/982277| - Y Y ALL COVERAGE
PURWODADI
1101 1226 RS. PANTI RAHAYU JL. LETJEND. SUPRAPTO NO.6 0292 - 421087-422325| 0292-421370/425095 Y Y ALL COVERAGE
PURWOKERTO
1102 1447 RSU. ANANDA PURWOKERTO JL. PEMUDA, NO.30 0281-631435-636417| 0281-640226/632146 Y Y ALL COVERAGE
1103 0201 RSU. BUNDA PURWOKERTO JL. PRAMUKA, NO.249 0281-635424/0281-632514|0281-632514 0281-632514 Y Y ALL COVERAGE
1104 4665 RSKB. JATIWINANGUN JL. JATIWINANGUN NO. 54, PURWOKERTO (0281) 638169| 081-623938 Y Y ALL COVERAGE
1105 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
1106 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
1107 3250 RS. ISLAM PURWOKERTO JL. HAJI MANSYURI NO.39 PURWOKERTO 0281-630019| -0281-635394 Y Y ALL COVERAGE
1108 2094 APOTEK KIMIA FARMA 133 PURWOKERTO JL. JEND. SUDIRMAN TIMUR NO. 435 0281-638546| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1109 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
1110 1351 RS. ORTHOPAEDI PURWOKERTO JL. SOEPARDJO ROESTAM NO. 99 PURWOKERTO 0281-6844166| 0281-6844188 Y Y ALL COVERAGE
1111 1448 RSIA. BUNDA ARIF PURWOKERTO JL. JATIWINANGUN, NO.16 PURWOKERTO 0281-636555| - Y Y ALL COVERAGE
PURWOREJO
1112 1908 RS. PALANG BIRU KUTOARJO JL. MADITOMO 17, KUTOARJO-PURWOREJO 0275-641425| - Y Y ALL COVERAGE
1113 4971 RS. ISLAM PURWOREJO JL. MAGELANG KM.2, LOANO (0275) 3255470| (0275) 325 570 Y Y ALL COVERAGE
1114 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
SALATIGA
1115 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
1116 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
1117 1145 RS. PURI ASIH JL. JEND. SUDIRMAN NO.169 0298-323209/0298-312049| 0298-322898/311466 Y Y ALL COVERAGE
SEMARANG
1118 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
1119 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
1120 3261 KIMIA FARMA 153 (JL. JATI RAYA BANYUMANIK) JL. JATI RAYA BANYUMANIK, SEMARANG 024-7464268| 024-7464268 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1121 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
1122 3264 KIMIA FARMA 271 MEDITAMA (JL. AHMAD) JL. KH. AHMAD DAHLAN NO. 9, KEL. BENDUNGAN, KEC. GAJAHMUNGKUR 024-8455323| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1123 3265 KLINIK & APOTEK 324 (JL. RAYA NGALIAN) JL. RAYA NGALIYAN , KEL. TAMBAK AJI, KEC.NGALIYAN SEMARANG 024-7612049| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1124 0182 RS. ISLAM SULTAN AGUNG JL. KALIGAWE KM.4 024-6580019| 024-6581928 Y Y ALL COVERAGE
1125 0901 RS. BANYUMANIK JL. BINA REMAJA NO.61 024-7471519/ 7462181|024-7462181 024-7462181 Y Y ALL COVERAGE
Page 16 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1126 0053 RS. ROEMANI MUHAMMADIYAH JL. WONODRI, NO.22 024 - 8444623| 024-8415752 Y Y ALL COVERAGE
1127 0050 RS. PANTI WILASA DR. CIPTO JL. DR. CIPTO, NO.50 024 - 3546040, 3557428| 024-3546042 Y Y ALL COVERAGE
1128 0299 RSU. HERMINA PANDANARAN SEMARANG JL. PANDANARAN NO.24 024-8411112/8442525| 024-8449077 Y Y ALL COVERAGE
1129 0160 RS. ST. ELISABETH - SEMARANG JL. KAWI NO. 1 024-8310076/ 8310035| 024-8413373 Y Y ALL COVERAGE
1130 1806 RSUP. DR KARIADI JL. DR SUTOMO NO.16 SEMARANG, JAWA TENGAH 024-8413476/8413993| 024-8318617 Y Y ALL COVERAGE
1131 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
1132 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
1133 1450 RS. PERMATA MEDIKA JL. MR.MOCH. ICHSAN, NO.93-97, NGALIYAN 024-7625005/7618800/7626571| 024-7621733 Y Y ALL COVERAGE
1134 0377 RS. TELOGOREJO JL. KH. AHMAD DAHLAN 024 - 8446000/8448448|024-8446000 024 - 8449660 Y Y ALL COVERAGE
1135 4457 RSIA GUNUNG SAWOJL. GUNUNG SAWO NO. 21 RT.08 RW. 04, KEL. PETOMPON, KEC.
GAJAHMUNGKUR, SEMARANG024-8315171| (024) 8412320; Y Y ALL COVERAGE
1136 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
1137 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
1138 3260 KIMIA FARMA 19 (JL. SULTAN AGUNG) JL. SULTAN AGUNG KOMPL. PERTOKOAN R A/15 SEMARANG 024-8315248| 024-8315795 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1139 3162 LAB. PRODIA SEMARANG (JL. JEND SUDIRMAN ) JL. JENDRAL SUDIRMAN NO.121 SEMARANG 024-7621757| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1140 3215 RS. WILLIAM BOOTH SEMARANG JL. S. PARMAN NO. 5 SEMARANG 024-8411800| Y Y ALL COVERAGE
1141 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
1142 5913 RSIA. BUNDA SEMARANG JL. BRIGJEND KATAMSO NO. 8, SEMARANG (024) 8413060| 024 - 8416037 Y Y ALL COVERAGE
1143 5430 RSIA ANUGERAH SEMARANG JL. KALISARI BARU NO.5-7 024-8313543| 024-8443016 Y Y ALL COVERAGE
1144 2822 RS. COLUMBIA ASIA SEMARANG JL. SILIWANGI NO. 143 SEMARANG (024) 762 9999/86462020| (024) 7667 4228 Y Y ALL COVERAGE
1145 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
1146 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
1147 2239 LAB. PRODIA SEMARANG JL. MT. HARYONO NO:882 SEMARANG 024-8444331| 024-8414308 N Y GP,LAB
1148 2969 RS. HERMINA BANYUMANIK JL. JENDRAL POLISI ANTON SOEDJARWO NO. 195 A, SEMARANG 50263 (024) 7648 8989| (024) 7647 9080 Y Y ALL COVERAGE
1149 1663 RS. KEN SARAS JL. SOEKARNO HATTA KM 029 024-6922269| 0298-522706 Y Y ALL COVERAGE
1150 3218 KLINIK KITA KALIPANCUR (DR MOEZ) JL. ABDULRAHMAN SALEH KAV. 783 KALIPANCUR, SEMARANG 024-7624455/ 085641869731| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1151 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
1152 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
1153 3246 LAB. CITO ( JL. SETIABUDI ) JL. SETIABUDI NO.120 A 024-7461645| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1154 3247 LABORATORIUM KLINIK CITO ( JL. DR. CIPTO ) JL. DR.CIPTO NO.14 A 024-3515374| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1155 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
1156 3230 KLINIK KITA KEDUNGMUNDU (DR MOEZ) JL. KEDUNGMUNDU RUKO GRAHA WAHID NO. 7, SEMARANG -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1157 3231 KLINIK IBNU SIENA PUSPONJOLO JL. PUSPONJOLO TENGAH RAYA NO.65 024-7609338| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1158 3232 KLINIK IBNU SIENA NGALIYAN JL. PROF HAMKA RUKO SEGITIGA EMAS B-7 024-76674346| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
SLAWI
1159 1665 RSU. ADELLA JL. PROF MOH YAMIN NO. 77 SLAWI 0283-491154/491773| 0283-491354 Y Y ALL COVERAGE
SOLO
1160 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
1161 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
1162 5911 RS. INDRIATI SOLO JL. PALEM RAYA LANGENHARJO, GROGOL, SOLO BARU, SUKOHARJO (0271) 5722 000| (0271) 5722 888 Y Y ALL COVERAGE
1163 0212 RS. ISLAM KUSTATI JL. KAPTEN MULYADI NO.249 0271 - 643013| 0271-634823 Y Y ALL COVERAGE
1164 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
1165 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
1166 0745 RS. ISLAM SURAKARTA JL. A YANI PABELAN KARTASURA, SOLO 0271-7105710271-725134|0271-725134 0271-710572 Y Y ALL COVERAGE
1167 0746 RS. PKU MUHAMMADIYAH SURAKARTA JL. RONGGOWARSITO NO130, SURAKARTA 0271-714578| 0271-717012 Y Y ALL COVERAGE
1168 1179 RS. BRAYAT MINULYA JL. DR.SETIABUDI NO.106 SURAKARTA 0271-716646,710170| 0271-727309/712181 Y Y ALL COVERAGE
1169 0214 RS. DR. OEN SURAKARTA(KANDANG SAPI) JL. BRIGJEN KATAMSO NO.55, KANDANG SAPI 0271-643139| 0271-642026 Y Y ALL COVERAGE
1170 1483 RS. PANTI WALUYO SURAKARTA JL. JEND.A.YANI NO.1 0271-712077| 0271-729125 Y Y ALL COVERAGE
1171 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
1172 0118 RS. DR. OEN SOLO BARU KOMP. PERUMAHAN SOLO BARU, GROGOL, SUKOHARJO 0271-620220| 0271-622555/660935 Y Y ALL COVERAGE
1173 2373 KLINIK 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
1174 2907 RS. HERMINA SOLO JL. KOL SUTARTO NO. 16 JEBRES SOLO 0271-638989| 271 Y Y ALL COVERAGE
SRAGEN
1175 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
1176 3353 APOTEK KIMIA FARMA 212 - SRAGEN JL. SUKOWATI NO.440A, SRAGEN MANGGIS 0271-892209| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
SUKOHARJO
1177 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
1178 1178 RS. NIRMALA SURI JL. RAYA SOLO KM 9 SUKOHARJO 0271-592192| - Y Y ALL COVERAGE
TEGAL
1179 3359 RSIA. PALA RAYA JL. PALA RAYA NO. 11 A MEJASEM 0283-356009| - Y Y ALL COVERAGE
1180 3219 LAB. PRODIA TEGAL JL. KAPTEN SUDIBYO NO. 136 TEGAL 0283-358673| 0283-353664 N Y GP,LAB
1181 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
1182 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
1183 1540 RS. MITRA KELUARGA TEGAL JL. SIPELEM, NO.4, KEMANDUNGAN, TEGAL BARAT 0283-340399/ 340999| 0283-340902 Y Y ALL COVERAGE
1184 0753 RS. ISLAM HARAPAN ANDA JL. ABABIL NO.420283-355717 /0283-359900 / 0283-
358244|0283-351263 Y Y ALL COVERAGE
TEMANGGUNG
1185 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
1186 1144 RS. NGESTI WALUYO JL. PAHLAWAN-PARAKAN 0293-596008| 0293-596410 Y Y ALL COVERAGE
1187 4508 RS. MUHAMMADIYAH TEMANGGUNG JL. RAYA KEDU KM.2 KALISAT TEMANGGUNG 56253 (0293) 596704, 596700, 4909900| (0293) 598700 Y Y ALL COVERAGE
WONOGIRI
1188 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
1189 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
Page 17 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
JAWA TIMUR
BANGIL
1190 0700 RS. ISLAM MASYITHOH JL. A. YANI, NO.6 0343-741018| 0343-742425 Y Y ALL COVERAGE
BANGKALAN
1191 3595 RS. LUKAS JL. KH.MOH.KHOLIL 36A 031-3095148| 031-3061367 Y Y ALL COVERAGE
1192 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
1193 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
BANYUWANGI
1194 1429 RS. YASMIN BANYUWANGI JL. LETKOL ISTIQLAL NO.80-84 0333-424671| -0333-418219 Y Y ALL COVERAGE
1195 0726 RS. ISLAM FATIMAH BANYUWANGI JL. JEMBER, NO.25 0333-421451| 0333-423204/417929 Y Y ALL COVERAGE
1196 0724 RS. AL-HUDA JL. DIPONEGORO, NO.65, GENTENG 0333-842033/844682/845248/842118| 0333-842036/38 Y Y ALL COVERAGE
1197 4065 RS. NAHDLATUL ULAMA BANYUWANGI JL. RAYA MANGIR NO. 09 KEC. ROGOJAMPI KAB. BANYUWANGI 0333-632965| 0333-632965 Y Y ALL COVERAGE
1198 4130 RSIA. PKU MUHAMMADIYAH ROGOJAMPI JL. PANGERAN DIPONEGORO NO. 20, ROGOJAMPI 0333-631149| - Y Y ALL COVERAGE
BLITAR
1199 3807 RS. UMUM AMINAH BLITAR JL. VETERAN NO. 39, KEPANJEN, KIDUL 0342-816304/816305| 0342-816527 Y Y ALL COVERAGE
1200 0269 RS. KATOLIK BUDI RAHAYU BLITAR JL. JEND. A.YANI NO. 18 BLITAR 0342-801066/802316/807802| 0342-806509/804284 Y Y ALL COVERAGE
1201 5908 LAB. PRODIA BLITAR JL MAWAR NO 82/74 KEL/KEC. SUKOREJO KOTA BLITAR 0342-803179| 0342-803179 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
BOJONEGORO
1202 1032 RS. PKU MUHAMMADIYAH KALITIDU JL. RAYA KALITIDU, NO.266, KALITIDU 0353-511731/512066-|- 0353-511678/512066 Y Y ALL COVERAGE
1203 0731 RS. AISYIYAH BOJONEGORO JL. HASYIM ASHAARI, NO.17 0353-881748/885978| 0353-885978 Y Y ALL COVERAGE
BONDOWOSO
1204 3892 RS. MITRA MEDIKA BONDOWOSO JL. HOS COKROAMINOTO 98, BONDOWOSO 0332-421981; 423800| 0332 429601 Y Y ALL COVERAGE
GRESIK
1205 0596 RS. SEMEN GRESIK JL. RA. KARTINI, NO.280 GRESIK 031 - 3987840,3989478,3975847| 031-3987842 Y Y ALL COVERAGE
1206 3842 KLINIK & APOTEK KF 164 (BM GRESIK) 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
1207 3648 RSUD. IBNU SINA KAB. GRESIK JL. DR. WAHIDIN SH NO.243B, GRESIK 031-3951239| - Y N H&S,MAT
1208 1427 RS. PETROKIMIA GRESIK (JL JEND SUDIRMAN) JL. JEND. A.YANI NO.69031-
3988877/3990994/3978658/3977666|031-3980008/3981232 Y Y ALL COVERAGE
1209 1923 RS. PETROKIMIA GRESIK GRHA HUSADA JL. PADI NO. 3 KOMPLEK PT PETROKIMIA GRESIK 031-3984465,3973400,3793401| 031-3972623 Y Y ALL COVERAGE
1210 4522 RS. SURYA MEDIKA JL. LABAN KULON NO. 58 MENGANTI GRESIK 61174, JAWA TIMUR (031) 7914025| 031-7911889 Y Y ALL COVERAGE
1211 4235 RS. FATHMA MEDIKA GRESIK JL. PENDOPO NO. 45, SEMBAYAT, MANYAR, GRESIK (031) 394 3500| - Y Y ALL COVERAGE
1212 4966 KLINIK MEDIS PUSURA MENGANTI RUKO MENGANTI MAS BLOK U-2, JL RAYA BRINGKANG, MENGANTI, GRESIK 031-5471707| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1213 4053 RS. PETROKIMIA GRESIK DRIYOREJO JL. RAYA LEGUNDI KM 5 031-8986701, 8981779, 8981778| 031-8986700 Y Y ALL COVERAGE
1214 4078 LAB. PARAHITA GRESIK JL. R.A KARTINI NO 120 031-3981455| 031-3991820 N Y LAB
1215 2610 RS. WATES HUSADA JL. RAYA WATES UTARA KEDUNGPRING, BALONGPANGGGANG - GRESIK (031) 7922351| - Y Y ALL COVERAGE
JEMBER
1216 0725 RS. PERKEBUNAN (PTPN) X JEMBER JL. BEDADUNG, NO.20331-
487104,485415,426873,485912,410748030331-485912 Y Y ALL COVERAGE
1217 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
1218 1685RSU. KALIWATES PT PERKEBUNAN NUSANTARA
XIIJL. DIAH PITALOKA NO 1 JEMBER
0331-
3137525/483567/488964/485967/4891000331-489100 Y Y ALL COVERAGE
1219 2342 THC JEMBER JALAN LETJEN SUPRAPTO NO. 65 JEMBER 0331-339725| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1220 3530 RS. CITRA HUSADA JL. TERATAI NO.22 JEMBER (0331) 486200| (0331) 427088 Y Y ALL COVERAGE
1221 1428 RS. BINA SEHAT JL. JAYANEGARA NO.7 0331-422701/424304/421713| 0331-428390 Y Y ALL COVERAGE
1222 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
JOMBANG
1223 1849 RSIA. MUSLIMAT JOMBANG JL. URIP SUMOHARJO NO 34 JOMBANG 0321-872200/877600/869434| 0321-854991 Y Y ALL COVERAGE
1224 0978 RS. KRISTEN MOJOWARNO JL. MERDEKA NO.59, MOJOWARNO 0321-495093-|- 0321-492200/495440 Y Y ALL COVERAGE
1225 1880 RS. AIRLANGGA JOMBANG JL. AIRLANGGA NO 50 C JELAKOMBO, JOMBANG 0321-861577| 0321-862194 Y Y ALL COVERAGE
1226 1966 RS. PELENGKAP MEDICAL CENTER JL. JUANDA NO. 03 JOMBANG 0321-877945 / 869826| - Y Y ALL COVERAGE
1227 0810 RS. DR. MOEDJITO DWIDJOSISWOJO JL. HAYAM WURUK, NO.9 JOMBANG 0321-864308,6977788,855555| 0321-877276 Y Y ALL COVERAGE
1228 5425 RS. NAHDLATUL ULAMA JOMBANG JL. KH. HASYIM ASHARI NO.211 0321-878700| 0321-878700 Y Y ALL COVERAGE
KEDIRI
1229 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
1230 0977 RS. BAPTIS KEDIRI JL. BRIDJEN POLLBH PRANOTO NO.1 0354-682170, 683578, 684172-|- 0354-681173 Y Y ALL COVERAGE
1231 1430 RS. AURA SYIFA JL. JOYOBOYO NO.42 DLOPO 0354-671939 / 682316| 0354-696033/641939 Y Y ALL COVERAGE
1232 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
1233 4680 RS. MUHAMMADIYAH SITI KHODIJAH KEDIRI JL. DR. SOETOMO 322 SUKOREJO, KEC. GURAH, KAB. KEDIRI, JAWA TIMUR (0354) 545481; 546593| (0354) 548838 Y Y ALL COVERAGE
1234 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
1235 0248 RS. HVA TOELOENGREDJO JL. A. YANI NO. 25 PARE 0354-391047,391145| 0354-392883 Y Y ALL COVERAGE
1236 1599 RS. MUHAMMADIYAH AHMAD DAHLAN KEDIRI JL. GATOT SUBROTO NO 84 KEDIRI 0354-773115/770182| 0354-776318/773736 Y Y ALL COVERAGE
1237 6376 KLINIK SURYA KEDIRI JL. TUNGGUL WULUNG NO.15 KARANGREJO, NGASEM 085216577778| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1238 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
LAMONGAN
1239 1199 RS. MUHAMMADIYAH LAMONGAN JL. JAKSA AGUNG SUPRAPTO 0322-322834| 0322-314048 Y Y ALL COVERAGE
1240 4782 RS. ISLAM NASHRUL UMMAH JL. MERPATI NO.62 0322-321522| - Y Y ALL COVERAGE
1241 4765 RS. KH. ABDURRAHMAN SYAMSURI (ARSY) JL. RAYA DEANDLES KM. 74 PACIRAN LAMONGAN (0322) 666626 / 081232870229| (0322) 666626 Y Y ALL COVERAGE
LUMAJANG
1242 2724 RS. ISLAM LUMAJANG JL. KYAI MUKSIN 19 LUMAJANG 0334-887999/893535| (0334) 887778 Y Y ALL COVERAGE
1243 1247 RS. WIJAYA KUSUMA JL. A. YANI, NO.149, LUMAJANG 0334-891325| 0334-888844 Y Y ALL COVERAGE
MADIUN
1244 1183 RS. SITI AISYAH MADIUN JL. MAYJEN SUNGKONO, NO.38 0351-464822/451843/452010| 0351-464009 Y Y H&S,MAT
1245 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
1246 3200 RS. GRIYA HUSADA MADIUN JL. MAYJEND PANJAITAN NO.22 MADIUN 0351 - 472801 / 472802 / 472803| 0351 475900 Y Y ALL COVERAGE
1247 0722 RS. SANTA CLARA JL. BILITON, NO.15 0351-462688/452770/464571| 0351-455780/466509 Y Y ALL COVERAGE
1248 3421 LAB. PRODIA MADIUN JL. SULAWESI NO.9 MADIUN 0351453344| - N Y GP,LAB
1249 2345 THC MADIUN JALAN MANGGIS NO.9, MADIUN 0351-77542120| 0351-476697 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
Page 18 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
MALANG
1250 0815 RS. PANTI WALUYA SAWAHAN JL. NUSAKAMBANGAN NO.5 0341-362017,366033,361507| 0341-354068 Y Y ALL COVERAGE
1251 0708 RS. LAVALETTE JL. W.R. SUPRATMAN, NO.10 0341-470805/482612| 0341-470804 Y Y ALL COVERAGE
1252 2790 RSIA. GALERI CANDRA JL. BUNGA ANDONG NO.3 MALANG 65141 (0341) 478571| (0341) 478571 Y Y ALL COVERAGE
1253 1327 RSIA. HUSADA BUNDA JL. PAHLAWAN TRIP NO. 2, ORO-ORO DOWO (0341) 569634; 566972;569799; 580169| 0341-580169/569799 Y Y ALL COVERAGE
1254 2068 RS. LAWANG MEDIKA JL. DR CIPTO NO.8, KEL.BEDALI, KEC.LAWANG 0341-7057623/420888| - Y Y ALL COVERAGE
1255 2048 RS. PRIMA HUSADA MALANG JL. BANJARARUM SELATAN NO. 3, MONDOROKO SINGOSARI-MALANG 0341-458679| 0341-441874 Y Y ALL COVERAGE
1256 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
1257 1326 RS. WAVA HUSADA KEPANJEN JL. PANGLIMA SUDIRMAN NO.99A KEPANJEN 0341-393000| 0341-398398 Y Y ALL COVERAGE
1258 1325 RS. MARSUDI WALUYO JL. RAYA MONDOROKO KM.9 SINGOSARI 0341-458974| 0341-451579 Y Y ALL COVERAGE
1259 1252 RS. ISLAM MALANG ( UNISMA ) JL. MAYJEND HARYONO NO. 139 0341-551356,580798,565448| 0341-551257 Y Y ALL COVERAGE
1260 0252 RS. ISLAM AISYIYAH MALANG JL. SULAWESI, NO.16 0341-326773| 0341-368883 Y Y ALL COVERAGE
1261 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
1262 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
1263 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
1264 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
1265 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
1266 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
1267 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
1268 4089 RS. ISLAM GONDANGLEGI JL. HAYAM WURUK NO 66, GONDANGLEGI 0341 - 879047| - Y Y ALL COVERAGE
1269 2967 PERSADA HOSPITAL JL. PANJI SUROSO ARAYA BUSINESS CENTER KAV.II-IV 0341-2996333| 0341-2993773 Y Y ALL COVERAGE
1270 4524 RS. PRASETYA HUSADA JL. RAYA NGIJO NO. 25 KARANGPLOSO KAB. MALANG JAWA TIMUR (0341) 460558| (0341) 463404 Y Y ALL COVERAGE
1271 3437 RSB. MARDI WALOEJA RAMPAL JL. WR. SUPRATMAN NO.01 MALANG (0341) 364756| - Y Y ALL COVERAGE
1272 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
1273 0609 RS. PANTI NIRMALA JL. KEBALEN WETAN, NO.2-8 0341-362459| 0341-327930 Y Y ALL COVERAGE
1274 0125 RSIA. MELATI HUSADA JL. KAWI, NO.320341-325249 / 3570341 / 341357|0341-
3413570341-365094/341357 Y Y ALL COVERAGE
1275 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
1276 0192 RS. BAPTIS BATU JL. RAYA TLEKUNG NO.1 JUNREJO, BATU0341-594161 /0341-598192/5|0341-
598192/50341-598911 Y Y ALL COVERAGE
1277 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
1278 4172 RSU UNIVERSITAS MUHAMMADIYAH MALANG JL. TLOGOMAS NO. 45 MALANG 0341 561666| 0341 561627 Y Y ALL COVERAGE
1279 3611 RSI. MADINAH KASEMBON JL. RAYA SUKOSARI NO. 32 KASEMBON MALANG 0354-326688/ 393000| 0354-328144 Y Y ALL COVERAGE
1280 2789 RSIA. PURI MALANG JL. TAMAN SLAMET NO.20 MALANG 0341-325329| (0341) 342322 Y Y ALL COVERAGE
1281 0094 RSU. HERMINA TANGKUBANPRAHU MALANG JL. TANGKUBAN PRAHU, NO.33 MALANG0341-325082 - 354844 - 354845/460341-
354844/8|0341-354844/80341-354843 Y Y ALL COVERAGE
1282 1561 RS. PERMATA BUNDA MALANG JL. SOEKARNO HATTA NO. 75, LOWOKWARU 0341-487487/407462| 0341-474242 Y Y ALL COVERAGE
1283 1978 RS. MUTIARA BUNDA MALANG JL. CIUJUNG NO.19 (0341) 400403; 400722| - Y N ALL COVERAGE
1284 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
MOJOKERTO
1285 0088 RS. KARTINI MOJOKERTO JL. ERLANGGA, NO.137, MOJOSARI 0321-592261| 0321-595569 Y Y ALL COVERAGE
1286 0785 RS. EMMA JL. RAYA IJEN WATES NO.67 0321-396747|- 0321-334021 Y Y ALL COVERAGE
1287 1980 RS. SIDO WARAS JL. RAYA PASAR SAWAHAN KM. 10 BANGSAL KAB. MOJOKERTO 0321-598621| 0321-598624 Y Y ALL COVERAGE
1288 1997 RS. ISLAM HASANAH MUHAMMADIYAHJL. HOS. COKROAMINOTO NO.26 - 28, MAGERS. ARI,MOJOKERTO, JAWA
TIMUR 613130321-321635| - Y Y ALL COVERAGE
1289 3825 RSI. SAKINAH JL. RA BASUNI NO.12 MOJOKERTO 0321-321922| 0321-329670 Y Y ALL COVERAGE
1290 0928 RS. GATOEL MOJOKERTO JL. RADEN WIJAYA NO.56 0321-321681,322329,399772-|- 0321-321684 Y Y ALL COVERAGE
1291 0164 RS. REKSA WALUYA JL. MOJOPAHIT, NO.4220321-322170/3221710321-
322171/3937|0321-322171/39370321-322511 Y Y ALL COVERAGE
1292 2818 RS. MUTIARA HATI JL. RAYA KEMANTREN WETAN 49, TERUSAN,GEDEG, MOJOKERTO (0321) 7223400, 363442| - Y Y ALL COVERAGE
NGAWI
1293 3872 RS. AT-TIN HUSADA JL. RAYA NGAWI-SOLO KM 4 0351747888| 351747666 Y Y ALL COVERAGE
PACITAN
1294 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
1295 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
1296 0113 RS. LARASATI JL. MANDILARAS, NO.74, PAMEKASAN 0324-328305| 0324-322080 Y Y ALL COVERAGE
PASURUAN
1297 1347 RS. MITRA SEHAT MEDIKA JL. BY PASS NO.6 PANDAAN 0343-636064| 0343-636083 Y Y ALL COVERAGE
1298 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
PONOROGO
1299 3869 RS. DARMAYU PONOROGO JL. Dr. Soetomo No.44 - 50 0352-481320| 0352-461253 Y Y ALL COVERAGE
1300 0823 RSU. AISYIYAH PONOROGO JL. DR SUTOMO NO.18-24 0352-481784,461560,485093| 0352-484218 Y Y ALL COVERAGE
PROBOLINGGO
1301 0309 RS. DHARMA HUSADA JL. SOEKARNO HATTA NO.10 0335-422176| 0335-422698 Y N H&S,MAT
1302 4081 RS. RIZANI JL. RAYA SURABAYA SITUBONDO KM 135, KEL SUMBEREJO, KEC PAITON 0335 773444| - Y Y ALL COVERAGE
1303 1330 RSU. WONOLANGAN JL. RAYA DRINGU NO.118 0335-424007| 0335-431937 Y Y ALL COVERAGE
SIDOARJO
1304 1040 RS. MITRA KELUARGA WARU JL. RAYA LETJEN. S.PARMAN, NO.8 031-8543111/8542111-|- 031-8534333 Y Y ALL COVERAGE
1305 4077 LAB. PARAHITA DARMO PERMAI JL. RAYA DARMO PERMAI 1/56 031-7326650| 031-7328511 N Y LAB
1306 6375 RS. RAHMAN RAHIM JL. RAYA SAIMBANG RT/RW:10/03 KEBON AGUNG, SUKODONO 031-8830010| - Y Y ALL COVERAGE
1307 2755 RSU. BUNDA SIDOARJO JL. KUNDI NO.70 KEPUH KIRIMAN, WARU SIDOARJO (031) 8668880| (031) 8688218 Y Y ALL COVERAGE
1308 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
1309 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
1310 1108 RSAB. SOERYA JL. RAYA KALIJATEN, NO.11-15, TAMAN SEPANJANG 031-7885011-|- 031-7873633 Y Y ALL COVERAGE
1311 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
1312 0249 RS. DELTA SURYA JL. PAHLAWAN NO.9031-8962531-8961271031-8961271|031-
8961271031-8961281/8944977 Y Y ALL COVERAGE
1313 1346 RS. CITRA MEDIKA SIDOARJO JL. RAYA SURABAYA, KM.44, KRAMAT TUMENGGUNG 0321-361000| 0321-361666/362956 Y Y ALL COVERAGE
1314 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
1315 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
1316 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
1317 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
1318 3199 RSIA. KIRANA SIDOARJO JL. RAYA NGELOM 87 TAMAN - SIDOARJO 031-7881623| 031-7873010 Y Y ALL COVERAGE
Page 19 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1319 4706 KLINIK IBU & ANAK PONDOK JATI JL. PONDOK JATI AK 9-13 PAGERWOJO BUDURAN (031) 8052062| (031) 8052037 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1320 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
1321 0545 RS.SITI KHODIJAH SIDOARJO JL. PAHLAWAN, NO.260, SEPANJANG031-
7881130,7882123,7872081,60134373|031-7876066 Y Y ALL COVERAGE
1322 0271 RS. ISLAM SITI HAJAR SIDOARJO JL. RADEN PATAH NO.70 031-8921233/8961570| 031-8944438/8944990 Y Y ALL COVERAGE
1323 2054 RSIA. ARAFAH ANWAR MEDIKA SUKODONO JL. SAWO NO. 2 DUNGUS, SUKODONO, SIDOARJO 031-8830989| 031-8831089 Y Y ALL COVERAGE
1324 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
1325 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
1326 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
SITUBONDO
1327 3096 RS. ELIZABETH PTP NUSANTARA XI JL. WR SUPRATMAN 2A SITUBONDO 0338-671174| 0338-678061 Y Y ALL COVERAGE
SURABAYA
1328 0809 RS. SPESIALIS HUSADA UTAMA JL. PROF DR MOESTOPO 31-35031- 5017975/5018335(021)
9100682|(021) 9100682031-5010777 Y Y ALL COVERAGE
1329 0081 SILOAM HOSPITALS SURABAYA JL. RAYA GUBENG NO. 70, SURABAYA 031-5031333/5031821| 031-5031533/5039313 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 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
1332 1052 RSIA. PUSURA TEGALSARI (MEDIS PUSURA 4) JL. TEGAL SARI NO.59 031-5473462-|- 031-5462033 Y Y ALL COVERAGE
1333 2001 RS. WIYUNG SEJAHTERA JL. KARANGAN PDAM NO.1-3 WIYUNG SURABAYA (031) 7532653| (031) 7533726 Y Y ALL COVERAGE
1334 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
1335 0828 RS. AL. DR.RAMELAN SURABAYA JL. GEDUNG NO.1 SURABAYA (031) 8438153 / 031-8438154| (031) 8437511 Y Y ALL COVERAGE
1336 4076 LAB. PARAHITA DIPONEGORO JL. DIPONEGORO 161-163 031-5610011| - N Y LAB
1337 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
1338 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
1339 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
1340 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
1341 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
1342 2925 RS. MITRA KELUARGA KENJERAN JL. KENJERAN 506 (031) 99000880| (031) 99000885 Y Y ALL COVERAGE
1343 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
1344 4446 RSIA KENDANGSARI MERR JL. DR. IR. H. SOEKARNO NO. 2, SURABAYA (031) 3814388| (031) 3813488 Y Y ALL COVERAGE
1345 0829RS. PREMIER SURABAYA (RS. SURABAYA
INTERNASIONAL)JL. NGINDEN INTAN BARAT, BLOK B 031- 5993211|031-5993211 031- 5993214 Y Y ALL COVERAGE
1346 4209 RS. WIJAYA SURABAYA JL. MENGANTI 398 WIYUNG SURABAYA 031-7523087/031-7523282| Y Y ALL COVERAGE
1347 4231 RSIA NUR UMMI NUMBI (NUN) SURABAYA JL. MANUKAN TENGAH BLOK 51J/4-6 (031) 740 4391 ; 741 5313| - Y Y ALL COVERAGE
1348 3538 LAB. PARAHITA DHARMAWANGSA JL. DHARMAWANGSA 66 SURABAYA 031-5020552,5020081,5013705-6| 031-5032676, 5023551 N Y LAB
1349 4799 RSIA. CEMPAKA PUTIH PERMATA SURABAYA JL. JAMBANGAN KEBON AGUNG NO. 8, SURABAYA (031) 8282350| (031) 8297578 Y Y ALL COVERAGE
1350 3197 RS. SURABAYA MEDICAL SERVICE JL. KAPUAS NO. 2 SURABAYA 031-5686161| - Y Y ALL COVERAGE
1351 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
1352 4128 LAB. PRODIA BOGOWONTO JL. BOGOWONTO NO.14 ( PUSAT GMC ) 031-5631818| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1353 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
1354 1365 RS. MATA UNDAAN JL. UNDAAN KULON, NO.19 031-5343806/531619| 031-5317503 Y Y ALL COVERAGE
1355 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
1356 4082 RS. ISLAM DARUS SYIFA JL. RAYA BENOWO NO. 5 SURABAYA 0317406293| - Y Y ALL COVERAGE
1357 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
1358 0830 RS. ADI HUSADA UNDAAN WETAN JL. UNDAAN WETAN NO40-44 dan 50 031-5321256/031-5318000|031-5318000 031- 5321081 Y Y ALL COVERAGE
1359 0136 RS. MITRA KELUARGA SURABAYA JL. SATELIT INDAH II, DARMO SATELIT 031-7345333| 031-7345955 Y Y ALL COVERAGE
1360 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
1361 0546 MEDIS PUSURA JL. KOM ( L) YOS SUDARSO, 9A 031-5340604 / 031-5471707/5328920| 031-5327095 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1362 1000 RS. MUJI RAHAYU JL. RAYA MANUKAN WETAN 68 A, SURABAYA 031-7404132/709837250000000|0000000 - Y Y ALL COVERAGE
1363 0163 RS. DARMO JL. RAYA DARMO, NO.90 031 - 567 6253/54/55/56| 031-5620690 Y Y ALL COVERAGE
1364 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
1365 0544 RS. ST.VINCENTIUS A.PAULO (RS. RKZ) JL. DIPONEGORO NO.51031-
5677562/5687846/5663895031/5687846|031-5674748/5651057 Y Y ALL COVERAGE
1366 0895 RS. PHC SURABAYA JL. PRAPAT KURUNG SELATAN NO.1 TANJUNG PERAK 031-3294801/2/3|- 031-3294804 Y Y ALL COVERAGE
1367 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
1368 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
1369 2315 NATIONAL HOSPITAL SURABAYA BOULEVARD FAMILI SEL KAV 1 GRAHA FAMILI, SURABAYA 031-2975777| 031-297799 Y Y ALL COVERAGE
1370 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
1371 2476 RS. ROYAL SURABAYA JL. RUNGKUT INDUSTRI I/ 1 SURABAYA 031-8476111| 031-8476211 Y Y ALL COVERAGE
1372 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
1373 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
1374 1690 RS. BEDAH SURABAYA JL. RAYA MANYAR NO 9 SURABAYA 031-5999369,5999339| 031-5995284 Y Y ALL COVERAGE
1375 1364 RS. ISLAM SURABAYA JEMURSARI JL. JEMURSARI NO.51-57 031 - 8471877/8471878/8471889| 031-8437784 Y Y ALL COVERAGE
1376 1362 RS. BHAKTI RAHAYU SURABAYA JL. KETINTANG MADYA I/16 031-8295922/8291799/8299217/23| 031-8293839 Y Y ALL COVERAGE
1377 1363 RS. BUNDA SURABAYA JL. RAYA KANDANGAN NO.23-24 BENOWO 031 - 7442220/7440077/7400694| 031 - 7442133 Y Y ALL COVERAGE
1378 1453 RS. ONKOLOGI ARAYA GALAXI BUMI PERMAI BLOK A2/7 JL. ARIEF RAHMAN HAKIM 182 031-5914855| 031-5914860 Y Y ALL COVERAGE
1379 1454RSIA. PUTRI ( RS. KHUSUS OBSTETRI &
GINEKOLOGI )JL. ARIF RAHMAN HAKIM, NO.122 031-5999987| 031-5997215 Y Y ALL COVERAGE
1380 1201 RS. ADI HUSADA KAPASARI JL. KAPASARI NO.97-101 031-3764555| 031-3764666 Y Y ALL COVERAGE
1381 0980 RS. ISLAM SURABAYA JL. JEND A YANI NO.2-4 031-8284505;8284506;8284507|- 031-8291805 Y Y ALL COVERAGE
1382 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
1383 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
1384 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
1385 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
1386 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
1387 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
1388 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
1389 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
1390 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
1391 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
1392 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
1393 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
1394 2785 RS. ORTHOPEDI DAN TRAUMATOLOGY JL. EMERALD MANSION TX 10 CITRALAND, SURABAYA (031) 57431299| (031) 57431255 Y Y ALL COVERAGE
Page 20 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1395 2786 RS. PURA RAHARJA JL.PUNCANG ADI 12-14 (031) 5019898/ 5022151/ 5024591| - Y Y ALL COVERAGE
1396 2217 RS. KENDANG SARI SURABAYA JL. RAYA KENDANGSARI NO.38 SURABAYA 031-8436200/8437200| 031-8494484 Y Y ALL COVERAGE
1397 3390 RSIA. LOMBOK DUA DUA ( JL. FLORES) JL. FLORES NO. 12 SURABAYA 031- 5022044| - Y Y ALL COVERAGE
TUBAN
1398 1198 RS. MEDIKA MULIA TUBAN JL. MOJOPAHIT, NO.699 TUBAN 0356-322744/324618| 0356-322666 Y Y ALL COVERAGE
1399 2002 RS. NAHDLATUL ULAMA TUBAN JL. LETDA SUCIPTO NO 211 TUBAN 0356-328244/(0356) 328299| (0356) 712072 Y Y ALL COVERAGE
TULUNG AGUNG
1400 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
1401 3826 RS. ERA MEDIKA JL. RAYA PULOSARI, NGUNUT, TULUNGAGUNG, JAWA TIMUR 0355-398706/396566/ 08155199111| 0355-398706 Y Y ALL COVERAGE
1402 0813 RS. ISLAM ORPEHA JL. KH. R. ABDUL FATAH 0355-323186| 0355-327691 Y Y ALL COVERAGE
1403 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
KALIMANTAN BARAT
KETAPANG
1404 1800 RS. FATIMA KETAPANG JL. JEND SUDIRMAN NO. 27 KETAPANG 0534-32814| 0534-31649 Y Y ALL COVERAGE
MELAWI
1405 5633 RS. KASIH BUNDA JAYAJL. JUANG KM.1 NANGA PINOH, TANAH TINGGI RT.003/004 DESA TANJUNG
NIAGA0568-22885| Y Y ALL COVERAGE
1406 5627 RS. CITRA HUSADA MELAWIJL.DHARMA BAKTI NO.45C DUSUN TANAH TINGGI DESA TANJUNG NIAGA
KEC.NANGA PINOH KAB.MELAWI0568-22355| 0568-21645 Y Y ALL COVERAGE
PONTIANAK
1407 2729 RS. MITRA MEDIKA PONTIANAK JL. SULTAN ABDURRAHMAN NO.25, PONTIANAK, KALBAR (0561) 584888| - Y Y ALL COVERAGE
1408 2679 KIMIA FARMA SERDAM (SUNGAI RAYA DALAM) JL. SUNGAI RAYA DALAM RUKO B1 0561-737797| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1409 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
1410 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
1411 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
1412 1431 RSIA. ANUGERAH BUNDA KHATULISTIWA JL. AHMAD YANI NO. 5-7 0561-581818/085249922000| 0561-584100 Y Y ALL COVERAGE
1413 1106 RS. SANTO ANTONIUS JL. KH. WAHID HASYIM NO.249 0561-732101-|- 0561-742242/733623 Y Y ALL COVERAGE
1414 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
SANGGAU
1415 4108 RS. SENTRA MEDIKA SANGGAU JL. CEMPAKA KEL. ILIR KOTA RT.013/RW.OO3, KEC. KAPUAS 78513 (0564) 24240| (0564) 24248 Y Y ALL COVERAGE
SINGKAWANG
1416 1368 RS. SANTO VINCENTIUS SINGKAWANG JL. P. DIPONEGORO NO.5 0562-631008/636768| 0562-633881 Y Y ALL COVERAGE
1417 2621 RSU. HARAPAN BERSAMA JL. N. P. BELITUNG NO. 61) SINGKAWANG 0562-631791| 0562-633359 Y Y ALL COVERAGE
KALIMANTAN SELATAN
BANJARBARU
1418 5424 CIPUTRA MITRA HOSPITAL JL. A. YANI KM. 7.8 BANJARMASIN, KALIMANTAN SELATAN 05116743999| - Y Y ALL COVERAGE
1419 2709 RSIA. LEMBAYUNG HUSADA JL. A. YANI KM 36 SIMPANG EMPAT (0511) 4777115| Y Y ALL COVERAGE
1420 5781 RS. SYIFA MEDIKA BANJARBARU JL. R.O ULIN NO. 93, BANJARBARU, KALIMANTAN SELATAN 70712 0511-5910889| Y Y ALL COVERAGE
1421 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
1422 3572 PRODIA BANJARMASIN JL. JEND. ACHMAD YANI KM 3.5 NO. 131 - 133 BANJARMASIN 70235 0511-3273500| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1423 0631 RS. SARI MULIA JL. PANGERAN ANTASARI NO. 139B0511 - 3252570/3274447/3261491/0511-
266960|0511-2669600511 - 3257889 Y Y ALL COVERAGE
1424 0849 RS. ISLAM BANJARMASIN JL. LET JEN S PARMAN GG.PURNAMA NO.88 BANJARMASIN0511-3350332, 3354896, 3350335|0511-
3350332/350511-3351690 Y Y ALL COVERAGE
1425 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
1426 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
1427 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
1428 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
1429 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
1430 2471 KLINIK MEDIKA BATULICIN JL.RAYA BATULICIN - SERONGGO KM.1 SEI KECIL, TANAH BUMBU 0518-71570| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
KANDANGAN
1431 1799 RS. PAHLAWAN MEDIKA CENTER JL. PAHLAWAN NO. 15 KANDANGAN KAB. HULU SUNGAI SELATAN 0517-23191| 0517-23678 Y Y ALL COVERAGE
MARTAPURA
1432 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
1433 1797 RSIA. MUTIARA BUNDA MARTAPURA JL. TAISIR NO. 2, MARTAPURA O511- 4721901| 0511- 4720664 Y Y ALL COVERAGE
1434 2721 RS. PELITA INSANI JL. SEKUMPUL NO.66 MARTAPURA 70614, KALIMANTAN SELATAN (0511) 4722210/ 4722220| (0511) 4722230 Y Y ALL COVERAGE
TABALONG
1435 2707 RS. PERTAMINA TANJUNGJL. GAS, KOMPERTA MURUNG PUDAK TANJUNG, KALIMANTAN SELATAN
71571(0526) 2022550/2023068| (0526) 2027678 Y Y ALL COVERAGE
TANAH BUMBU
1436 3996 KLINIK SIMPANG TANAH BUMBUJL. GAWE SABUMI RT 08 NO. 083, DESA BERSU. JUD,KEC. SIMPANG
EMPAT, KAB. TANAH BUMBU, KALIMANTAN SELATAN 72200(081258339911 / 081953230699)| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1437 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
1438 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
1439 2673 KLINIK & APOTEK KF 112 (BM PALANGKARAYA) JL. DIPONEGORO NO.8, PAHANDUT 0536 -3221952| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1440 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
1441 2889RS. ISLAM PKU MUHAMMADIYAH
PALANGKARAYAJL. RTA MILONO KM .2,5 MENTENG, JEKAN RAYA 0536-3244801-4803| 0536-3239444 Y Y ALL COVERAGE
PANGKALAN BUN
1442 3529 KLINIK KESUMA JL. ISKANDAR NO.12 A, PANGKALAN BUN 0532-2065244 / (0532) 23935| (0532) 23935 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1443 4676 RS. CITRA HUSADA PANGKALAN BUNJL. MALIJO, MADUREJO, ARUT SELATN, KOTAWARINGIN BARAT,
KALIMANTAN TENGAH(0532) 2070777| (0523) 2070789 Y Y ALL COVERAGE
SAMPIT
1444 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
1445 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
KALIMANTAN TIMUR
BALIKPAPAN
1446 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
1447 3459 SUMATERA EYE CENTRE BALIKPAPAN RUKO SENTRA EROPA BLOK AA 2B NO.16 BALIKPAPAN BARU (0542) 876732/876941| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1448 0686 PANACEA CLINIC KOMP MAL FANTASI BLOK AB2 NO.18-20 BALIKPAPAN BARU 761140542-877898,72040460751-
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
1449 0692 APOTIK KANIDA FARMA II JL. JEND. SUDIRMAN, NO. 239 0542-424309,0542 420496|0542-420496 0542-424031 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
Page 21 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1450 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
1451 0672 RSIA. PERMATA HATI BALIKPAPAN JL. IMAM BONJOL NO.1 0542-413932/413928| 0542 - 413928 Y Y ALL COVERAGE
1452 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
1453 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
1454 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
1455 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
1456 1213 RS. BALIKPAPAN BARU KOMP. BALIKPAPAN BARU JL. MT.HARYONO BLOK. A-A3 0542-877330| 0542-877331 Y Y ALL COVERAGE
1457 1374SILOAM HOSPITALS BALIKPAPAN (RS
BALIKPAPAN HUSADA)JL. MT.HARYONO NO.9 RINGROAD 0542 - 8862 999| 0542-7206517 Y Y ALL COVERAGE
1458 2634 KLINIK & APOTEK KF 425 SEPINGGAN JL. MARS. MA ISWAHYUDI NO. 702 0542 7210391| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1459 5912 RS. HERMINA BALIKPAPAN JL. MT.HARYONO NO.45, SEPINGGAN BARU, BALIKPAPAN SELATAN 0542 - 8532525| 0542 - 8508989 Y Y ALL COVERAGE
1460 0633 RS. PERTAMINA BALIKPAPAN JL. JEND SUDIRMAN NO.1 0542-7517485/734020/21| 0542-7517493 Y Y ALL COVERAGE
1461 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
1462 0632 RS. RESTU IBU BALIKPAPAN JL. JEND. A. YANI, NO.120542-427342/3/40542-427342|0542-
4273420542-441494/417290 Y Y ALL COVERAGE
BATU KAJANG
1463 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
1464 3189 RSI. BONTANG ( YABIS ) JL. BRIGJEN KATAMSO NO. 40 BONTANG 0548 - 20003| 0548-22644 Y Y ALL COVERAGE
1465 2118 RS. AMALIA BONTANG JL. R. SOEPRAPTO NO. 22 BONTANG BARU, KOTA BONTANG KALTIM 0548-25050| 0548-23275 Y Y ALL COVERAGE
1466 1214 RS. PUPUK KALTIM BONTANG JL. OKSIGEN NO.1, KOMP.PUPUK KALTIM 0548-41118/41444| 0548-41555 Y Y ALL COVERAGE
1467 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
1468 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
KUTAI KARTANEGARA
1469 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
1470 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
PASER
1471 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
SAMARINDA
1472 1794 RSIA. THAHA BAKRIE JL. PANGERAN HIDAYATULLAH NO 11 SAMARINDA 0541-742191| 0541-200075 Y Y ALL COVERAGE
1473 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
1474 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
1475 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
1476 2453 RS. SAMARINDA MEDIKA CITRA JL. KADRIE OENING NO.81 RT.35 SAMARINDA 75124 (0541) 7273000| (0541) 7272888 Y Y ALL COVERAGE
1477 0230 RS. H. DARJAD JL. DAHLIA, NO.4 0541-732698,734123,732609| 0541-732562 Y Y ALL COVERAGE
1478 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
1479 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
1480 3575 PRODIA SAMARINDA JL. A. YANI KOMP. CENDRAWASIH TRADE CENTER BLOK A-6, SAMARINDA (0541) 736198| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1481 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
1482 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
1483 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
1484 5666 KLINIK KUMALA JL. P. ANTASARI NO. 33 B RT. 02 SAMARINDA 75124 (0541) 735602/ 769357| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1485 2473 RS. SIAGA RAMANIA JL. RAMANIA 3 ( JL. JEND. SOEPARTO) SAMARINDA, KALTIM 0541-739772| 0541-749131 Y Y ALL COVERAGE
SANGATTA
1486 1376RS. PKT PRIMA SANGATTA (RS. PUPUK KALTIM
)JL. YOS SUDARSO I NO.1 SANGATTA 0549-24555 / 085828779475| 0549-24524; 25927 Y Y ALL COVERAGE
1487 1801 RS. SOHC JL. YOS SUDARSO IV, NO. 1, TELUK LINGGA 0549-23417| 0549-23417 Y Y ALL COVERAGE
1488 1556 RS. MELOY SANGATTA JL. YOS SUDARSO II NO.101 0549-2026258| 0549-24222 Y Y H&S,MAT
KALIMANTAN UTARA
BULUNGAN
1489 4681 KLINIK BUNYU MEDIKA JL. EMPLASMEN RT. 07 DESA BUNYU TIMUR, KAB. BULUNGAN (0511) 2055374| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
TARAKAN
1490 4731 RSUD. TARAKAN (KALIMANTAN UTARA) Jl. PULAU IRIAN NO.1, KAMPUNG SKIP (0551) 21720/21166| (0551) 21720 Y Y ALL COVERAGE
1491 1972 RUMKITAL ILYAS TARAKAN JL. MARTADINATA NO 29 0551-24320 / 21353| - Y Y ALL COVERAGE
1492 1529 RS. PERTAMINA TARAKAN JL. MULAWARMAN NO. 14, TARAKAN 0551-31403/31665| 0551-33310 Y Y ALL COVERAGE
LAMPUNG
BANDAR LAMPUNG
1493 5605 RSIA BELLEZA KEDATON JL.SULTAN HAJI LABUHAN RATU 0721-773333| 0721-773338 Y Y ALL COVERAGE
1494 1092 RS. MITRA HUSADA PRINGSEWU JL. JEND A. YANI NO.14 PRINGSEWU, LAMPUNG 0729-23792-|- 0729-23836 Y Y ALL COVERAGE
1495 1228 RS. BUMI WARAS JL. WOLTER MONGINSIDI, NO.235 0721-254589/261122/257925/267855| 0721-257926 Y Y ALL COVERAGE
1496 1692 RS. HARAPAN BUNDA LAMPUNG JL. RAYA LINTAS SUMATERA NO.30 SEPUTIH JAYA LAMPUNG TENGAH 0725-26766| 0725-25091 Y Y ALL COVERAGE
1497 1693 RSIA. MUTIARA PUTRI JL. HOS COKROAMINOTO NO 76 ENGGAL LAMPUNG 0721-252579/254999| 0721-254282 Y Y ALL COVERAGE
1498 0486 RS. IMMANUEL WAY HALIM JL. SOEKARNO-HATTA, WAY HALIM 0721-704900,704630/628| 0721-704807/784897 Y Y ALL COVERAGE
1499 1970 RSIA. BUNDA ASY-SYIFA JL. DR.SUSILO NO. 54 PAHOMAN TELUK BETUNG UTARA BANDAR LAMPUNG 0721-259259/256256| 0721-266800 Y Y ALL COVERAGE
1500 1871 RS. PERTAMINA BINTANG AMIN JL. PRAMUKA NO 27, LAMPUNG 0721-273601| 0721-273597 Y Y ALL COVERAGE
1501 1378 RS. URIP SUMOHARJO JL. URIP SUMOHARJO NO.200 SUKARAME 0721-771322/23/24| 0721-771321/707990 Y Y ALL COVERAGE
1502 0487 RS. ADVENT LAMPUNG JL. TEUKU UMAR, NO.48 KEDATON BANDAR LAMPUNG 0721-703459| 0721-786349/770717 Y Y ALL COVERAGE
1503 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
1504 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
1505 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
1506 2176 RSIA. RESTU BUNDAJL. K.H. HASYIM ASHARI NO. 73, TELUK BETUNG SELATAN - BANDAR
LAMPUNG0721-484158/484185| 0721-482832 Y Y ALL COVERAGE
1507 2465 RSIA. PURI BETIK HATI JL. PAJAJARAN NO.109, JAGABAYA, BANDAR LAMPUNG, LAMPUNG 0721-787799| - Y Y ALL COVERAGE
1508 2767 RS. ISLAM ASY-SYIFAAJL. NEGARA LINTAS SUMATERA KM.65 YUKUM JAYA - BANDAR JAYA, KEC.
TERB. ANGGI BESAR, LAMPUNG TENGAH 34162(0725) 25264| (0752) 527476 Y Y ALL COVERAGE
Page 22 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1509 2725 THC TELKOM MEDIKA LAMPUNG EX. GEDUNG PLASA TELKOM JL. SULTAN AGUNG NO. 1 BANDAR LAMPUNG 0721703044/ 704999| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1510 1352 RS. GRAHA HUSADA LAMPUNG JL. GAJAH MADA, NO. 6 GH, TANJUNG AGUNG, BANDAR LAMPUNG 0721-240000| 0721-263181/268417 Y Y ALL COVERAGE
1511 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
1512 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
LAMPUNG SELATAN
1513 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
1514 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
METRO
1515 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
NATAR
1516 1632 RS. NATAR MEDIKA (YADIKA GROUP) JL. RAYA NATAR NO. 04 MUARA PUTIH, KEC NATAR LAMPUNG SELATAN 0721-92521/92519| 0721-92519 Y Y ALL COVERAGE
TANJUNG HARAPAN
1517 2921 RSU. HANDAYANIJL. N. SOEKARNO - HATTA NO : 94, TANJUNG HARAPAN, KOTABUMI,
LAMPUNG UTARA0724328399| Y Y ALL COVERAGE
MALUKU
AMBON
1518 2265 APOTEK KIMIA FARMA PEL.26 AMBON,MALUKUJL. 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
1519 2911 RS. T TK.II DR.J.A. LATUMETEN JL. DR. TAMAELA N0. 2 AMBON 0911-353555| 0911-354763 Y Y ALL COVERAGE
1520 1439 RS. BHAKTI RAHAYU AMBON JL. BATU KERB. AU, BELAKANG RRI 0911-342746| - Y Y ALL COVERAGE
1521 2912 RS. SUMBER HIDUP JL. ANTHONY RHEBOK, HONIPOPU, SIRIMAU, AMBON, MALUKU (0911) 352373, 351654| 0911-352401 Y N H&S,MAT
1522 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
MALUKU UTARA
TERNATE
1523 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
1524 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
1525 2012 RS. ISLAM TERNATE JL. PEMUDA NO. 131 KEL.TOBELEU 0921-3121623| - Y N ALL COVERAGE
1526 1503 RS. MEDIKA HARIFALM JL. ZAINAL ABIDINSYAH, NO.25, KOMPLEX POHON PALA 0921-3126087| 0921-3126198 Y N H&S,MAT
NAD
BANDA ACEH
1527 4836 RS. PERTAMEDIKA UMMI ROSNATIJL. SEKOLAH MO. 5 GAMPONG ATEUK PAHLAAWN KEC. BAITURRAHMAN
KOTA BANDA ACEH(0651) 35092| - Y Y ALL COVERAGE
1528 2962 KLINIK PRODIA BANDA ACEH JL. T.H.M. DAUD BEUREUH NO. 45 B-C, BANDA ACEH 23126 (0651) 23823, 637807| (0651) 22387 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1529 1790 RS. CEMPAKA AZ ZAHRA JL. POCUT BAREN NO 36-38-40 BANDA ACEH 0651-31066| 0651-25281 Y N ALL COVERAGE
1530 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
1531 2186 APOTEK KIMIA FARMA ACEH (37) JL. DIPONOGORO NO 8 0651-21559| 0651-635 669 N Y GP,SP,OP,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-RB,PHAR
1532 4816 RS. MEUTIA JL. CUT MEUTIA NO. 55 KP. BARU, BANDA ACEH (0651) 33149| Y Y ALL COVERAGE
1533 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
1534 1100 RS. TEUNGKU FAKINAH JL. JEND. SUDIRMAN NO.27-29 0651-41454 / 081377028888-|- 0651-47646/49454 Y N H&S,MAT
BIREUN
1535 6082 RSU. JEUMPA HOSPITALJL. BANDA ACEH-MEDAN KM. 220 NO. 102 DUSUN TERATAI GAMPONG
GEULANGGANG BARO, KEC. KOTA JUANG, KAB. BIREUEN, ACEH(0644) 324150| - Y Y ALL COVERAGE
1536 1694 RS. TELAGA BUNDA BIERUN JL. PEUTUA BANTA NO.7, GP BIREUN 0644-324433| 0644-324433 Y Y ALL COVERAGE
LANGSA
1537 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
1538 2711 RS. CUT MEUTIA JL. GARUDA NO. 1 KEL. KEBON BARU (0641) 425314 / 4811339| (0641) 426285 Y Y ALL COVERAGE
LHOKSEUMAWE
1539 1892 RSU. SAKINAH LHOKSEUMAWE JL. ANTARA NO.30 0645-45534/42158| - Y N H&S,MAT
1540 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
1541 1975 KLINIK VINCA ROSEAJL. DARUSSALAM NO. 36 KP JAWA BARU, KOTA LHOKSEUMAWE - ACEH
UTARA0645-7011117 / 46725/ 085338437373| 0645-630218 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1542 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
1543 4212 KLINIK CEMPAKA LIMA MEULABOH JL. SWADAYA NO 39 F/39 G MEULABOH082361103699/08116822077/081269802
42|N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1544 3686 RS. SWASTA MONTELLA JL. BERINGIN JAYA SAMPING MESJID AGUNG, MEULABOH, ACEH BARAT (0655) 7551974; 085277358711| - Y Y ALL COVERAGE
PIDIE
1545 4106 KLINIK MUTIARA SIGLI JL. PROF A. MADJID IBRAHIM NO. 10, SIGLI, PIDIE, ACEH 24151 0653-21529| 0653-24565 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
SIGLI
1546 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
NTB
BIMA
1547 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
1548 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
LOMBOK TIMUR
1549 1894 RS. ISLAM NAMIRA SELONG JL. KH AHMAD DAHLAN NO 7. KEC SELONG KOTA SELONG 0376-22693/21004/| - Y Y ALL COVERAGE
1550 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
1551 1783 RS. RISA SENTRA MEDIKA LOTIM JL. PEJANGGIK NO.78 A RAKAM, SELONG 0376-23888| 0376-23999 Y Y ALL COVERAGE
MATARAM
1552 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
1553 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
1554 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
1555 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
1556 4358 RS. GRHA ULTIMA MEDIKA (Group Siloam) JL. MAJAPAHIT NO. 10, MATARAM (0370) 623999; 628111| +62370 - 635955 Y Y ALL COVERAGE
1557 1957 RSIA. PERMATA HATI MATARAM JL. MAJAPAHIT NO 10 0370-631999| 0370-632999 Y Y ALL COVERAGE
1558 1956 RSI. SITI HAJAR MATARAM JL. CATUR WARGA NO. 6 MATARAM 0370-623498| - Y Y ALL COVERAGE
1559 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
1560 1645 RS. HARAPAN KELUARGA MATARAMJL. AHMAD YANI NO. 9 SELAGALAS, SANDUBAYA, MATARAM - LOMBOK
(NTB)0370-670000,6177027,6177000| 0370-673666 Y Y ALL COVERAGE
1561 4688 KLINIK PRATAMA ASY-SYIFA JL. PANJI TILAR NEGARA NO. 136 MATARAM -| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1562 1124 RSB. EXONERO JL. PEMUDA NO.16, DASAN AGUNG 0370-636454,644440| 0370-647023/636454 Y Y ALL COVERAGE
1563 1539 RS. RISA SENTRA MEDIKA JL. PEJANGGIK, NO.115, CAKRANEGARA0370-632117/0370) 632117 / 0878 651
29354 / 089 7090 1005/06/56/0370-0370-625559 Y Y ALL COVERAGE
1564 1827 RS. BIOMEDIKA JL. BUNG KARNO NO 143 MATARAM 0370-645137| 0370-645138 Y Y ALL COVERAGE
Page 23 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
SUMBAWA
1565 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
1566 3500 APOTEK KF 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
1567 2972 RS. KARTINI KUPANG JL. FRANS SEDA NO.17,KELURAHAN TUAK DAUN MERAH, KUPANG-85228 0380-80265111/0380 - 831 270| (0380) 831270 Y Y ALL COVERAGE
1568 4099 RSIA. LEONA JL. SOEVARDI NO. 20 OEBUFU, KUPANG 0380-840212 - 0811 3818 622| 0380-840212 Y Y ALL COVERAGE
1569 3464 RS. WIRASAKTI JL. MOH. HATTA KUPANG (0380)-821131 / 0380-824735| - Y Y ALL COVERAGE
1570 2240 RS. ST CAROLUS BORROMEUS JL. HR. KOROH KM. 08 BELLO KUPANG 0380 - 8030530, 085100030530| - Y Y ALL COVERAGE
1571 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
1572 3975 SILOAM HOSPITALS KUPANG JL. RW MONGINSIDI RT. 014 RW. 004 FATUTULI 0380-8530900/8530911| 0380-8530933 Y Y ALL COVERAGE
1573 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
1574 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
1575 1647 RSIA. DEDARI JL. RANTAI DAMAI 69 D TDM OEBUFU KUPANG-NTT 0380-8553914/826774| 0380-830041/8553914 Y Y ALL COVERAGE
1576 2242 KLINIK & APOTEK KF 135 KUPANG Jl. M.Hatta 46 Kupang 0380- 830944/820541/831296| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1577 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
LABUHAN BAJO
1578 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
1579 3616 LAB. KLINIK PRODIA MAUMERE JL. EL TARI, KEL. MADAWAT, KEC. ALOK, MAUMERE FLORES (0382) 21146| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
PAPUA
JAYAPURA
1580 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
1581 1469 RS. DIAN HARAPAN JL. TARUNA BHAKTI KEL YABANSAI DISTRIK HERANG - JAYAPURA0967-573479/ 572325; 0852 4400
4655;0813 44100 432|0967-573362/573979 Y Y ALL COVERAGE
1582 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
MERAUKE
1583 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
1584 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
1585 2716 RS. KASIH HERLINA TIMIKA JL. A.YANI NO. 37 (0901) 321433/321443 / 082398124027| (0901) 324310 Y Y ALL COVERAGE
PAPUA BARAT
MANOKWARI
1586 4181RS. ANGKATAN LAUT DR AZHAR ZAHIR
MANOKWARIJL. SERMA SUWANDI NO. 1 0986-211758; 0822-38980-504| - Y Y ALL COVERAGE
SORONG
1587 6454 RS. KASIH HERLINA SORONG JL. SELAT MAKASAR NO.7 REMU, SORONG 0951-321424| - Y Y ALL COVERAGE
1588 1475 RS. PERTAMINA SORONG JL. AHMAD YANI NO. 13 0951-321362, 321581| 0951-326110 Y Y ALL COVERAGE
RIAU
DUMAI
1589 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
1590 1621 KLINIK RAWAT INAP & BERSALIN PADU SERASI JL. JEND. SUDIRMAN NO. 188 DUMAI, RIAU 0765-438189 / 438289| 0765-438008 Y Y ALL COVERAGE
1591 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
DURI
1592 0624 RSIA. MUTIA SARI JL. BATHIN BETUAH, NO.1-A, SIMPANG PADANG 0765-93635/92080| 0765-597972/55979 Y Y ALL COVERAGE
1593 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
1594 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
1595 0930 RSU. THURSINA JL. HANGTUAH NO.93 0765-597782 / 595573|0765-595573 0765-597773 Y Y ALL COVERAGE
1596 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
PANGKALAN KERINCI
1597 1369 RS. EFARINA PANGKALAN KERINCI JL. LINTAS TIMUR NO 1, PANGKALAN KERINCI, KAB PELALAWAN 0761-494500/493980| 0761- 493981 Y Y ALL COVERAGE
PEKANBARU
1598 4853 RS. PRIMA PEKANBARUJL. BIMA NO. 1 NANGKA UJUNG, KEL. DELIMA KEC. TAMPAN, PEKANBARU,
RIAU(0761) 8419007| (0761) 8419006 Y Y ALL COVERAGE
1599 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
1600 4511 RS. A. YANI PEKANBARU JL. JEND. A. YANI NO. 73, PEKANBARU (0761) 856370| - Y Y ALL COVERAGE
1601 4739 AULIA HOSPITAL PEKANBARU JL. HR.SUBRANTAS No. 63, PANAM 0761-6700 000| (0761) 854815 Y Y ALL COVERAGE
1602 2926 RSIA. ANDINI JL. TUANKU TAMBUSAI NO.55, PEKANBARU (0761) 33612 / 33850| (0761) 33649 Y Y ALL COVERAGE
1603 0625 RS. SANTA MARIA PEKANBARU JL. A. YANI, NO.68 0761-28800,20235,20166,22213| 0761-26071 Y Y ALL COVERAGE
1604 0664 RS. ISLAM IBNU SINA PEKANBARU JL. MELATI, NO.60 0761-24242/26011| 0761-35698 Y Y ALL COVERAGE
1605 0841 RSIA. ZAINAB JL. RONGGOWARSITO I NO.1 0761-24000| 0761-859448 Y Y ALL COVERAGE
1606 5205 RS. MATA PEKANBARU EYE CENTERJL. SOEKARNO HATTA NO.236 KEL.SIDOMULYO TIMUR, KEC MARPOYAN
DAMAI07617875191-92| 0761-7875195 Y Y ALL COVERAGE
1607 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
1608 0920 RS. AWAL BROS PEKANBARU JL. JEND. SUDIRMAN NO.117 0761-47333-|- 0761-47222 Y Y ALL COVERAGE
1609 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
1610 0663 RSIA. ERIA BUNDA JL. KH. AHMAD DAHLAN, NO.163 0761-23100/23600| 0761-47235 Y Y ALL COVERAGE
1611 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
1612 2102 APOTEK KIMIA FARMA 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
1613 1596 RS. KHUSUS BEDAH & KEBIDANAN SYAFIRA JL. JEND.SUDIRMAN NO.134 PEKANBARU 0761-856517,35360| 0761-41887 Y Y ALL COVERAGE
1614 2409 RSIA. BUDHI MULIA JL.SOEKARNO HATTA NO.226-228 ARENGKA, PEKANBARU 0761-3069900/8417200| 0761-8417255 Y Y ALL COVERAGE
1615 2590 RSB. ANNISA TANGKERANGJL. GARUDA NO. 66 TASKURUN UNJUNG TANGKERANG TENGAH,
PEKANBARU(0761) 848 652| (0761) 848 652 Y Y ALL COVERAGE
1616 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
1617 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
1618 1535 EKA HOSPITAL PEKANBARU JL. SOEKARNO HATTA, KM.6,5 0761-6989999| 0761-6989944 Y Y ALL COVERAGE
ROKAN HILIR
1619 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
1620 4136 KLINIK UTAMA CAHAYA JL. LINTAS RIAU UJUNG TANJUNG KAB. ROKAN HILIR 081-266818300| - Y Y ALL COVERAGE
Page 24 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
ROKAN HULU
1621 1878 RS. AWAL BROS UJUNG BATU JL. JEND. SUDIRMAN NO. 314 UJUNG BATU ROKAN HULU RIAU 0762-7363329| 0762-7363334 Y Y ALL COVERAGE
RIAU KEPULAUAN
BATAM
1622 2503 RS. GRAHA HERMINE KOMP. RUKO ASIH RAYA NO.9-15, BATU AJI (0778) 363318, 363127| (0778) 363164 Y Y ALL COVERAGE
1623 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
1624 4336 KLINIK DUNIA MEDICAL CENTRE RUKO PERUMNAS FANINDO BLOK B NO. 7-10, BATAM 29432, KEP. RIAU (0778) 7432 899| (0778) 3581209 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1625 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
1626 6018 KLINIK MUTIARA AISYAFA KOMPLEK RUKO TAMAN CARINA BLOK 3 NO.5 BATU AJI 0778-7432804 / 081374682228| 0778-7432804 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1627 1010 RS. ST. ELISABETH - BATAM JL. ANGGREK BLOK II, BALOI 0778 - 457357-|- 0778-457710/422473 Y Y ALL COVERAGE
1628 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
1629 0484 RB. BUDI ROSARI JL. MAHKOTA SIMPANG, NO.1, BENGKONG MAHKOTA 0778-427854| 0778-432833 Y Y ALL COVERAGE
1630 0582 RS. BUDI KEMULIAAN BATAM JL. BUDI KEMULIAAN, NO.1 0778-426865, 454044|0778-454044 0778-454055 Y Y ALL COVERAGE
1631 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
1632 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
1633 2480 KLINIK & APOTEK KF 128 KOMP. PERTOKOAN WIJAYA BLOK A NO. 4 SEI HARAPAN - BATAM 0778 323697| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1634 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
1635 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
1636 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
1637 0584 RS. AWAL BROS BATAM JL. GAJAH MADA KAV.1 BALOI 0778 - 431777| 0778-430777 Y Y ALL COVERAGE
1638 4838 RSIA. FRISDHY ANGEL JL. RADEN PATAH BLOK B NO. 1-3, LUBUK BAJA, BALOI, BATAM 0778-424 901/ 425134| Y Y ALL COVERAGE
BINTAN
1639 1240 RB. & BP TIARA MEDIKA JL. KAMPUNG HARAPAN RT 01/01 TELUK SASAH, TANJUNG UBAN 0771-484427| 0771-484427 Y Y ALL COVERAGE
1640 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
1641 2457 RSUD. TANJUNG UBAN JL. INDUN SURI SIMPANG BUSUNG NO.1 TANJUNG UBAN 29152 (0771) 482655/ 082324421982| - Y Y ALL COVERAGE
KARIMUN
1642 1271 RS. BAKTI TIMAH KARIMUNJL. CANGGAI PUTRI TELUK UMA KABUPATEN KARIMUN PROVINSI
KEPULAUAN RIAU 296610777-7367085| 0777-7333251 Y Y ALL COVERAGE
1643 5782 KLINIK NAYA MEDIKAJL. RAJA OESMAN RUKO TAMAN ANGGREK NO.5 BATU LIPAI RT.002 /001,
KEL.BARAN TIMUR, KEC. MERAL0777-327842| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1644 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
1645 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
1646 1237 KLINIK SAYANG IBU JL. AHMAD YANI, NO.20, BARAN SATU, MERAL, TANJUNG BALAI 0777- 216 76| 0777- 222 52 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1647 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
TANJUNG PINANG
1648 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
1649 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
1650 4416 KLINIK & APOTEK KF 169 JL. BRIGJEND. KATAMSO, TG.PINANG(JL. RAJA ALI HAJI KM 4 NO. 3) 0771 - 317631| N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1651 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
1652 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
SULAWESI BARAT
MAMUJU
1653 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
1654 4087 RSUD. MAMUJU JL. RE. MARTADINATA MAMUJU - SULBAR 0426-21107| - Y Y ALL COVERAGE
SULAWESI SELATAN
BONE
1655 4819 RS. HAPSAH JL. URIP SUMOHARJO, NO. X BONE 92731 (0481) 2911811| - Y Y ALL COVERAGE
MAKASSAR
1656 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
1657 2904 KLINIK PRODIA MAKASSAR (SADDANG) 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
1658 2905 KLINIK PRODIA MAKASSAR (JOKO WIDODO)JL. BOULEVARD RUKO RUBY I NO. 7-8, PANAKKUKANG MAS, MAKASSAR
90222 (PUSAT GMC - PPS PANAKKUKANG)(0411) 446666| (0411) 457000 N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1659 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
1660 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
1661 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
1662 1389 RS. GRESTELINA JL. LETJEN HERTASNING RAYA NO.51 0411-448855/448852| 0411-448854 Y Y ALL COVERAGE
1663 1390 RS. IBNU SINA YBW-UMI JL. URIP SUMOHARJO, KM.5, NO.264 0411-452958/5781595/452917| 0411-425397 Y Y ALL COVERAGE
1664 1393 RSIA. SITI KHADIJAH 1 MAKASSAR JL. KARTINI NO.15-17 MAKASSAR 0411-3624554/8614661| 0411-3627119 Y Y ALL COVERAGE
1665 0641 RS. STELLA MARIS MAKASSAR JL. SOMBA OPU NO.273, PO.BOX 122 0411-871391/873346| 0411 - 859545 Y Y ALL COVERAGE
1666 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
1667 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
1668 1630 RS. AWAL BROS MAKASSAR JL. JEND. URIP SUMOHARJO NO.43 MAKASSAR 0411-454567/455558| 0411-455123 Y Y ALL COVERAGE
1669 1190 RS. AKADEMIS JAURY YUSUF PUTERA JL. JEND. M YUSUF NO. 47A, PATTUNUANG0411-
3617343/3613054/3613071/3617344|0411-313914 Y Y ALL COVERAGE
1670 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
1671 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
1672 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
1673 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
1674 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
1675 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
1676 1847 SILOAM HOSPITALS MAKASSAR JL. METRO TANJUNG BUNGA KAV.9 PANAMBUNGAN, MARISSO0411-
3662900/8117555/8117430/5290000|0411-8117911 Y Y ALL COVERAGE
1677 3085 RS. UNIVERSITAS HASANUDDIN JL. PERINTIS KEMERDEKAAN KM.11 MAKASSAR 90245 0411 - 591331| - Y Y ALL COVERAGE
1678 3065 RSB. SENTOSA MAKASSAR JL. JEND. SUDIRMAN 52, 0411-3612720| (0411) 3619711 Y Y ALL COVERAGE
1679 5129 PARAHITA DIAGNOSTIC CENTER JL. GUNUNG LATIMOJONG NO.123 0411-3623573| N Y LAB
1680 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
1681 2178 APOTEK FARMARIN MAKASSAR JL. LANDAK LAMA NO 27, KEL LABUANG BAJI KEC MAMAJANG 0411-870397| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1682 5593 RS. HERMINA MAKASSARJL. TODDOPULI RAYA TIMYUR LORONG MAKASSAR BORONG KEC.
MANGGALA(0411) 4091817| (0411) 4091775 Y Y ALL COVERAGE
1683 5414 RSIA. PERMATA HATI MAKASSAR JL. TAMALANREA RAYA POROS BTP BLOK 10M NO.9-10 0411-4774085 / 582278| Y Y ALL COVERAGE
1684 6437 RSIA. PARAMOUNT MAKASSAR JL. ANDI PANGERAN PETTARANI NO.82 0411-4671666| 0411-4671999 Y Y ALL COVERAGE
Page 25 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1685 4985 RSU. WISATA UNIVERSITAS INDONESIA TIMUR JL. ABDUL KADIR NO. 70, MAKASSAR, 90224 (0411) 888444, 888666| (0411) 8115656 Y Y ALL COVERAGE
1686 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
PALOPO
1687 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
1688 0914 RS. AT MEDIKA JL. ANDI JEMMA, NO.09 0471-21596-|- 0471-23008 Y Y ALL COVERAGE
PARE PARE
1689 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
1690 1394 RS. FATIMA PARE-PARE JL. ILHAMV KOTAK POS 12 0421-21847| 0421-21328 Y Y ALL COVERAGE
SENGKANG
1691 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
1692 3577 KLINIK 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
1693 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
1694 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
1695 0639 RSU. WOODWARD (BALA KESELAMATAN) JL. LH. WOODWARD NO.1 0451 - 421769, 423744| 0451 - 423744 Y Y ALL COVERAGE
SULAWESI TENGGARA
BAU BAU
1696 4761 SILOAM HOSPITALS BUTONJL. SULTAN HASANUDDIN No. 58, KEL.BATULO, KEC.WOLIO KOTA BAUBAU,
SULAWESI TENGGARA0402-2825555| (0402) 2823020 Y Y ALL COVERAGE
1697 2300 RS. MURHUMJL. SULTAN MURHUM NO. 69 KEL. WAJO KEC. MURHUM SULTENG, BAU
BAU0402-2822650| 0402-2823919 Y Y ALL COVERAGE
KENDARI
1698 1537 RS. ST. ANNA JL. DR. MOH.HATTA, NO.65A 0401-3123092| 0401-3124872 Y Y ALL COVERAGE
1699 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
1700 2285KLINIK & APOTEK KIMIA FARMA 104 (BM
KENDARI)JL. HOMAMMAD HATTA NO.77, KENDARI BARAT 0401 -3127182| - N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1701 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
1702 6229 KLINIK DIAGNOSTIK RAPHA KENDARI JL. MALAKA NO. 25 ANDUONOHU, KENDARI 0401-3081484| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
SULAWESI UTARA
KOTAMOBAGU
1703 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
1704 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
1705 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
1706 1502 RS. ADVENT MANADO JL. 14 FEBRUARI, NO.1, TELING ATAS 0431-847950/858429| 0431-850012 Y Y ALL COVERAGE
1707 1798 SILOAM HOSPITALS MANADO JL. SAM RATULANGI NO 22 MANADO 0431-7290900| 0431-8883133 Y Y ALL COVERAGE
1708 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
1709 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
1710 2296 THC MANADO JALAN WR SUPRATMAN NO. 5 MANADO 0431- 843363| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1711 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
1712 2232 KLINIK & APOTEK KF WENANG 309 JL. LIMIMUNT NO. 12 A KEL. TIKALA KUMARAKA, KEC. WENANG, MANADO 0431-867163/840087| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1713 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
1714 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
1715 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
1716 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
1717 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
1718 5427 RS. MANADO MEDICAL CENTER JL. RAJAWALI NO.8, PAAL 2 0431-866641 / 082190285345| 0431-866641 Y Y ALL COVERAGE
SUMATERA BARAT
BUKIT TINGGI
1719 2114 KLINIK & APOTEK KF 146 BUKIT TINGGI JL. JEND. SUDIRMAN NO 14 BUKIT TINGGI 0752-35700| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1720 1398 RSU. MADINA JL. GURU HAMZAH NO.17 0752-21388 EXT 228| 0752-626677 Y Y ALL COVERAGE
1721 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
PADANG
1722 1320 RSI. SITI RAHMAH PADANG JL. RAYA BY PASS KM 15 AIE PACAH, PADANG 0751-463059| 0751-463531 Y Y ALL COVERAGE
1723 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
1724 0616 RS. YOS SUDARSO JL. SITUJUH, NO.1 0751-33230/33231| 0751-31811 Y Y ALL COVERAGE
1725 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
1726 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
1727 1569 RSIA. CICIK JL. DR. SUTOMO NO.94 MARAPALAM PADANG 25125 (0751) 38846; 38866| (0751) 841286 Y Y ALL COVERAGE
1728 0304 RS. SELAGURI JL. A.YANI, NO.26 0751 -33010/21953| 0751-840051 Y Y ALL COVERAGE
1729 4840 RSB. MUTIARA BUNDA JL. S. PARMAN NO. 142 PADANG, SUMATERA BARAT 0751-7054076| - Y Y ALL COVERAGE
1730 6420 RSIA. RESTU IBU PADANG JL TERAMDAN NO. 5-7 PADANG 0751-810756| 0751-31743 Y Y ALL COVERAGE
1731 4070 RSIA. ANNISA PADANG JL. PEMUDA NO. 18, PADANG (0751) 31906| (0751) 31905 Y Y ALL COVERAGE
1732 2369 RS. MATA PADANG EYE CENTER (PEC) JL. PEMUDA NO. 53 PADANG - SUMBAR 0751-30094| 0751-30098 Y Y ALL COVERAGE
1733 2714 SEMEN PADANG HOSPITAL JL. BY PASS KM 7 KEL. PISANG, KEC. PAUH (0751) 777888, 4782999., 4782997| (0751) 4782990 Y Y ALL COVERAGE
1734 4805 ZIRCONIC DENTAL CLINIC JL. H. AGUS SALIM NO. 57 B PADANG (0751) 841917; (0811666310)| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1735 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
1736 4051 RSIA. SITI HAWA JL. PARAK GADANG RAYA NO.35 0751-841251| - Y Y ALL COVERAGE
1737 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
1738 4195 RS. KHUSUS BEDAH ROPANASURI JL. ALUR NO.8 PADANG 0751-31938,33854| 0751-25735 Y Y ALL COVERAGE
PAYAKUMBUH
1739 1720 RSI. IBNU SINA PAYAKUMBUH JL. PEMUDA NO.14 0752-92222/90555| 0752-796744 Y Y ALL COVERAGE
1740 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
SUMATERA SELATAN
BATU RAJA
1741 1284 RS. SANTO ANTONIO JL. KOMISARIS UMAR NO. 33, BATURAJA 0735-320395/322418/324700| 0735-320201 Y Y ALL COVERAGE
Page 26 of 28
NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
LUBUK LINGGAU
1742 1869 KLINIK SEKATA JL. YOS SUDARS. O NO. 230 TABAH JEMEKEH, LUBUK LINGGAU 0733-321357| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1743 2715 RS. AR BUNDA LUBUK LINGGAU JL. GARUDA NO 245 RT 03 KEL. BANDUNG KIRI, KEC. LINGGAU BARAT 1 (0733) 324955/324963| (0733) 321892 Y Y ALL COVERAGE
MUARA ENIM
1744 5778KLINIK BERSALIN KARUNIA INDAH MEDIKA
(KIM)JL. MAYOR TJI AGUS KIEMAS LINTAS KEPUR - MUARA ENIM 081273373378| N Y
GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1745 4372 RS. BUKIT ASAM JL. Raya Bukit Asam No 118, Tanjung Enim Sumatera Selatan 0734-451096| - Y Y ALL COVERAGE
PALEMBANG
1746 1622 RS. HERMINA PALEMBANG JL. BASUKI RAHMAT NO.897 RT.011/003 KEL.20 ILIR II KEC.KEMUNING 0711-352525| 0711-366945 Y Y ALL COVERAGE
1747 1884 SILOAM SRIWIJAYA PALEMBANG JL. POM IX KEL. LOROK PAKJO KEC. ILIR BARAT 1 0711-5229100| 0711-5649100 Y Y ALL COVERAGE
1748 3965 RS. SRIWIJAYA EYE CENTER JL. JEND.SUDIRMAN KM. 4,5 NO.502 KEL. 20 ILIR, KEC. IT I (0711) 5611976/419680| Y Y ALL COVERAGE
1749 6116 RSIA. BUNDA NONI Jl. SRIJAYA NEGARA, RT.072 / 011 Kel. Bukit Lama Kec. Ilir Barat I (0711) 441952| - Y Y ALL COVERAGE
1750 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
1751 0883 RS. BUNDA PALEMBANG JL. DEMANG LEBAR DAUN, PALEMBANG0711-312866,3118660711-311866|0711-
3118660711-355553 Y Y ALL COVERAGE
1752 0688 RS. ISLAM SITI KHADIJAH PALEMBANG JL. DEMANG LEBAR DAUN, LORONG PAKJO 0711-356008/374440-2/310407| 0711-311884 Y Y ALL COVERAGE
1753 0627 RS. PUSRI JL. MAYOR ZEN, KOMPLEK PUSRI NO. 1 0711 -712222-712111| 0711-712071 Y Y ALL COVERAGE
1754 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
1755 0803 RS. MYRIA JL. KOL. H. BURLIAN KM. 7 NO 228 PALEMBANG 0711-411610/412433/421914| 0711-414052 Y Y ALL COVERAGE
1756 0817 RS. RK. CHARITAS JL. JEND. SUDIRMAN NO.10540711-350426/3533750711-
353374/5|0711-353374/50711-362205/377088 Y Y ALL COVERAGE
1757 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
1758 2423 RSIA. AZZAHRA PALEMBANG JL. BRIGJEN HASAN KASIM NO.1-2 BUKIT SANGKAL PALEMBANG 0711-822723| 0711-826044 Y Y ALL COVERAGE
1759 2442 KLINIK 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
1760 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
1761 2787 RS. PERTAMINA PLAJU PERTAMEDIKAJL. PENGANTINGAN NO.1 KOMPLEK PERTAMINA PLAJU SUMATERA
SELATAN 30268(0711) 597401/597442| (0711) 542388 Y Y ALL COVERAGE
1762 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
1763 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
PENUKAL ABAB LEMATANG ILIR
1764 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
1765 3953 RS. FADHILAH JL. JENDRAL SUDIRMAN NO. 01 PATIH GALUNG PRABUMULIH (0713) 3300032; 323939;| (0713) 3300032 Y Y ALL COVERAGE
1766 0824 RS. PERTAMINA PRABUMULIH JL. KESEHATAN, NO.100, KOMPLEK PERTAMINA PRABUMULIH0713-
383333/382749/322069/382742/382731(0713-321903/325181 Y Y ALL COVERAGE
1767 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
1768 2351 RS. SETIO HUSODO JL. S. M. RAJA N0 67 KISARAN, ASAHAN SUMATERA UTARA 0623-44999| 0623-43394 Y Y ALL COVERAGE
BINJAI
1769 1624 RSU. ARTHA MEDICA JL. SAMANHUDI NO. 22 BINJAI 061-8820387/8828167| 061-8830757 Y Y ALL COVERAGE
1770 6461 RSU. RATU MAS JL. TENGKU AMIR HAMZAH NO.281A BINJAI UTARA 061-8829404/8828173| - Y Y ALL COVERAGE
1771 2776 RSU. SYLVANI JL. N.PERINTIS KEMERDEKAAN.NO. 21 BINJAI (061) 80045925| (061) 80045923 Y Y ALL COVERAGE
1772 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
1773 1811 RS. BIDADARI BINJAI PERINTIS KEMERDEKAAN NO 174 A KEBUN LADA KOTA BIJAI 061- 8830003| 061 - 8826004 Y Y ALL COVERAGE
1774 1652 RS. LATERSIA JL. SOEKARNO HATTA, KM.18 NO.451, BINJAI 061-8829588/8829788| 061-8822565 Y Y ALL COVERAGE
BRASTAGI
1775 1542 RS. EFARINA ETAHAM BRASTAGI JL. JAMIN GINTING, NO.1, DESA RAYA, 0628-323716/17| 0628-213718 Y Y ALL COVERAGE
DELI SERDANG
1776 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
1777 4359 RS. THEOTOKOSJL.BESAR NAMORAMBE NO. 10 -15, KEC. NAMORAMBE DESA DELI TUA
MEDAN 20355(061) 7032854; 7032694;| (061) 7032806 Y Y ALL COVERAGE
KARO
1778 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
1779 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
1780 1653 RS. PERTAMINA PANGKALAN BRANDAN JL. WAHIDIN NO.01 PANGKALAN BRANDAN LANGKAT-SUMUT 0620-322612,322455| 0620-323392 Y Y ALL COVERAGE
LUBUK PAKAM
1781 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
1782 2023 RS. GRAND MEDISTRA LUBUK PAKAM JL. RAYA MEDAN-LUBUK PAKAM KM 25 NO. 66 061-7955114| 061-7950114 Y Y ALL COVERAGE
MEDAN
1783 0523 RS. ADVENT MEDAN JL. GATOT SUBROTO, KM. 4 061 - 4524875/4574025| 061-4154839 Y Y ALL COVERAGE
1784 0816 RS. METHODIST JL. MH. THAMRIN, NO.105 (061) 7369000| (061) 7363779 Y Y ALL COVERAGE
1785 0925 RS. ST ELISABETH - MEDAN JL. H. MISBAH NO.7, MEDAN 061-4144737/4522010/4144240| 061 - 4143168 Y Y ALL COVERAGE
1786 0742 RSU. MARTHA FRISKA JL. KOL. YOS SUDARSO KM.6, NO.91, PULO BRAYAN 061-6610910| 061-6612005 Y Y ALL COVERAGE
1787 1193 RSU. SARAH JL. BAJA RAYA NO. 10 PETISAH 061-4528044| 061-4529454 Y Y ALL COVERAGE
1788 1061 RS. ESTOMIHI JL. SISINGAMANGARAJA NO.235 MEDAN061-7861771,7864656061-7864656|061-
7864656061-7866660 Y Y ALL COVERAGE
1789 0741 RS. ISLAM MALAHAYATI JL. DIPENOGORO NO.2-4, MEDAN 061 - 4518766| 061-4519474 Y Y ALL COVERAGE
1790 0740 RS. HERNA JL. MAJAPAHIT NO.118A, MEDAN 061 -451 0766|IBU HENI/DR LIMENTA 061-415 3955 Y Y ALL COVERAGE
1791 1592 RSIA. STELLA MARIS MEDAN JL. SAMANHUDI NO.20 MEDAN 061-4158383| 061-4157088 Y Y ALL COVERAGE
1792 0626 RS. SARI MUTIARA JL. KAPTEN MUSLIM, NO.79 061-8451812| 061-8452134 Y Y ALL COVERAGE
1793 1649 RS. IMELDA PEKERJA INDONESIA JL. BILAL NO 24 PULO BRAYAN DARAT I MEDAN TIMUR 061-6610072-6631380| 061-6618457 Y Y ALL COVERAGE
1794 2028 RS. MITRA SEJATI MEDAN JL. AH. NASUTION PANGKALAN MAHSYUR NO.7, MEDAN 061-7875967/ 7881682| 061-7850261 Y Y ALL COVERAGE
1795 2053 MURNI TEGUH MEMORIAL HOSPITAL JL. JAWA NO. 2 SIMPANG JL. VETERAN 061-80501888/777| 061 - 80501800 Y Y ALL COVERAGE
1796 1651 RS. BUNDA THAMRIN MEDAN JL. SEI BATANG HARI NO. 28/30 MEDAN SUNGGAL
061-
4553928,88813615,4557318,4557218,455
3918|
061-4558218 Y Y ALL COVERAGE
1797 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
1798 0322 RSU. PERMATA BUNDA MEDAN JL. SISINGAMANGARAJA, NO.7061-7362777 / 7360120 / 7367980 EXT.
141|061-7320222 Y N ALL COVERAGE
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NOV-08-2017
No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed
LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA8-Nov-17
1799 0590RS. COLUMBIA ASIA MEDAN (D/H GLENI
MEDAN)JL. LISTRIK 2A MEDAN 061-4566368| 061-4566585/4515453 Y Y ALL COVERAGE
1800 4092 RSIA. SRI RATU JL. NIBUNG RAYA NO 204-212 MEDAN 061-4521074| 061-4539236 Y Y ALL COVERAGE
1801 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
1802 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
1803 1650 RS. MARTHA FRISKA MULTATULI JL. MULTATULI KOMP. MULTATULI INDAH NO 1 MEDAN 061-4149666 / 08286103148| 061-4154761 Y Y ALL COVERAGE
1804 4168 RS. KHUSUS BEDAH SETIA BUDI JL. MESJID NO. 3 TANJUNG REJO, MEDAN (061) 8220995 ; 8220996| (061) 8220955 Y Y ALL COVERAGE
1805 2876 KLINIK PRODIA MEDAN S PARMAN JL. LETJEND S PARMAN NO. 17/223 G LT LI 20153 MEDAN 061-4535731 / 4534903| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1806 4091 RSU. SUNDARI JL. TB SIMATUPANG NO 31 MEDAN 061-8452536-|- 061-8452536 Y Y ALL COVERAGE
1807 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
1808 3767 PRODIA MEDAN SETIA BUDI KOMPLEKS RUKO MILALA MAS BLOK A NO. 8, SETIA BUDI, MEDAN (061) 8224129| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1809 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
1810 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
1811 2179 APOTEK FARMARIN MEDAN JL. GATOT SUBROTO KM 4,2 NO. 311 MEDAN PETISAN 061- 4528454| 061- 4528464 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1812 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
1813 2438 E-LABS MEDAN JL. SENA NO.10 MEDAN 061-4101293| 061-4530850 N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1814 2395 SUMATERA EYE CENTER JL. ISKANDAR NO. 278 - 280, MEDAN 061-4525058 ; 4518222| 061-4510978 Y Y ALL COVERAGE
1815 2754 RS. DELI JL. MERBABU NO.18-20, MEDAN (061) 4565229| (061) 4552361 Y Y ALL COVERAGE
1816 0416 RS. MATERNA JL. TEUKU UMAR NO.11 061 -4514222| 061-4155392 Y Y ALL COVERAGE
1817 0773 RSU. PROF.DR.BOLONI JL. W. MONGINSIDI NO. 11 MEDAN (061) 4512687; 4556879; 4154637| (061) 4154621 Y Y ALL COVERAGE
1818 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
1819 6482 RSU. HERMINA MEDAN JL. ASRAMA/AMPERA II SEI SIKAMBING C-II MEDAN HELVETIA (061) 80862525/80867690| Y Y ALL COVERAGE
PADANG LAWAS
1820 4861 RSU. PERMATA MADINA SIBUHUANJL. KH. DEWANTARA SIHUBUAN KEC. BARUMUN KAB. PADANG LAWAS,
SUMUT(0636) 421211| (0636) 421311 Y Y ALL COVERAGE
PADANG SIDEMPUAN
1821 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
1822 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
1823 2209 APOTEK & KLINIK 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
1824 0719 RS. VITA INSANI JL. MERDEKA, NO.329 0622-22520| 0622-24521/29133 Y Y ALL COVERAGE
1825 2984 RS. HARAPAN PEMATANG SIANTAR JL. FAREL PASARIBU NO : 21 PEMATANG SIANTAR, SUMATERA UTARA 0622-21162, 21612| 0622-435301 Y Y ALL COVERAGE
1826 4418 KLINIK & APOTEK KF 162 JL. KARTINI PEMATANG SIANTAR 0622-22448| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1827 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
RANTAU PRAPAT
1828 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
1829 3566 LAB. PRODIA WIDYAHUSADA SIBOLGA JL. S.M. RAJA NO.74B 0631-22539| - N YGP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM-
RB,PHAR
1830 2249 RS. METTA MEDIKA SIBOLGA JL. SUTOYO SISWOMIHARJO NO.34 / JL. DIPENOGORO 6-8 SIBOLGA 0631-25007/25008/24001/24002| 0631-25006 Y Y ALL COVERAGE
TANJUNG BALAI
1831 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
TEBING TINGGI
1832 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
1833 6460 RS CHEVANI JLN. PROF M. YAMIN NO. 17 TEBING TINGGI 0621-3950222| 0621-3950221 Y Y ALL COVERAGE
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