LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 004 3422 LAB. PRODIA SINGARAJA JL. NGURAH RAI NO. 67 SINGARAJA 0362-24516| - N Y RB,PHAR 005 0870 RSU. KERTHA USADA JL. CENDRAWASIH, NO.5-7, SINGARAJA 0362-26277/8| 0362-22741 Y Y ALL COVERAGE

DENPASAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 006 2598 KLINIK & APOTEK KF 232 JL. RAYA KEROBOKAN 140, SEMINYAK, KUTA 0361 736163| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 007 2600 KLINIK & APOTEK KF 236 JL. DANAU BATUR RAYA, TM GRIYA, JIMBARAN 0361 8479785| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 008 1825 LAB. PRODIA WIDYA HUSADHA JL. NO. 192 DENPASAR (0361) 261001| (0361) 236349 N Y RB,PHAR 009 1245 RSU. SURYA HUSADHA UBUNG JL. COKROAMINOTO, NO.356, DENPASAR 0361-425744| 0361-430557 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 010 1202 KLINIK MERDEKA MEDICAL CENTER (MMC) MERDEKA VIII/2 TANJUNG BUNGKAK-DENPASAR 0361-233790| - N Y 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 0361-430270 / 430245 / 428287 / 013 1146 RS. BHAKTI RAHAYU DENPASAR JL. GATOT SUBROTO II, NO.11 0361-263371 Y Y ALL COVERAGE 7420673| GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 014 1463 KLINIK PENTA MEDIKA JL. BARAT-MARLBORO,NO.88 0361-7446144/490709| 0361 - 490708 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 019 0867 KLINIK&APOTEK KF 34 DENPASAR JL. DIPONEGORO NO.125, DENPASAR 0361-255914-|- 0361-255914 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 023 1151 KLINIK QUANTUM SARANA MEDIK JL. RAYA SESETAN, NO.20 0361-228835| 0361-245274 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 024 3455 APOTIK KIMIA FARMA NO.66 PATIMURA JL. PATIMURA NO.59 DENPASAR 0361-234797| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 025 2599 KLINIK & APOTEK KF 82 JL. KARTIKA PLAZA, NO.67, KUTA-BALI 0361 757196| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 026 4438 KLINIK UTAMA DHARMA SIDHI JL. SERMA KAWI NO. 13-17, DAUH PURI KELOD, DENPASAR BARAT (0361) 242717; 241013| 361241013 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 027 2602 KLINIK & APOTEK KF 108 JL. T.UMAR 246, DENPASAR 0361 245768| - N Y 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 JL. HAYANG SANGSI NO.2 PERUM CHANDRA AYU, BANJAR TUBUH, BATU 031 4075 RSU. PREMAGANA 0361-8461955/ 296389 / 082144049401| 0361-295246 Y Y ALL COVERAGE BULAN - SUKAWATI 032 4666 RS. FAMILI HUSADA JL. ASTINA TIMUR, SAMPLANGAN, KEC.GIANYAR, KAB. GIANYAR (0361) 849 3344| (0361) 8493040 Y Y ALL COVERAGE

JEMBRANA Jl. Hayam Wuruk No. 23 Ds. Dangintukadaya, Kec. Jembrana, Kab. 033 6026 RS. BALIMED NEGARA 0365-4501452| - Y Y ALL COVERAGE Jembrana 034 3558 RSU. BUNDA JL. RAJAWALI NO. 36, PENDEM, 0365-40251 / 087863229569| 0365-40089 Y Y ALL COVERAGE

KARANGASEM GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 035 2301 KLINIK PENTA MEDICA CANDIDASA JL. RAYA MANGGIS NO. 88, KAB. KARANGASEM, BALI 0363-41909| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 039 1492 KLINIK KASIH IBU KOMPLEKS PERUM BUMI DALUNG PERMAI, BLOK C1-C4 0361-422150/3700616| 0361-422179 N Y RB,PHAR NUSA DUA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 040 0222 KLINIK PRIMA MEDIKA JL. BY PASS NGURAH RAI, PERTOKOAN NIAGA, NO.81 0361-770509| 0361-770509 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 041 2603 KLINIK & APOTEK KF 126 JL. BY PASS NGURAH RAI NO 890,NUSA DUA 0361 778555| - N Y RB,PHAR 042 1359 RSU. SURYA HUSADHA NUSA DUA JL. SILIGITA, BLOK 1, NO.14 0361-775827| 0361-771388 Y Y ALL COVERAGE

SANUR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 043 2604 KLINIK & APOTEK KF 173 JL. BY PASS NGURAHRAI 232,SANUR 0361 283395| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 044 1248 KLINIK REMEDIUM CARE JL. BY PASS NGURAH RAI NO.243 0361-288860| 0361-287970 N Y RB,PHAR TABANAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 045 4520 PRODIA TABANAN JL. NGURAH RAI NO. 43 KEDIRI TABANAN 0361-812758| - N Y RB,PHAR 046 1714 RS. WISMA PRASANTI JL. YAH GANGGA NO. 9 TABANAN , BALI 0361-8043219/810555| 0361-812454 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 047 3456 APOTIK & KLINIK KIMIA FARMA.102 TABANAN JL. NGURAH RAI NO.74 A TABANAN 0361-810524| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 049 0224 UBUD CLINIC JL. TJAMPUHAN, NO.36, P.O.BOX 10, UBUD, GIANYAR 0361-974911| 0361-974910 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 052 4769 KLINIK BAKTI TIMAH TANJUNG PANDAN JL. MELATI NO. 32 TANJUNG PENDAM 33416 0719-21865| - N Y RB,PHAR 053 2370 RS. ALMAH TANJUNG PANDAN JL. JEND. KM. 11 NO. 1 KODE POS 33144 0719-9225666| 0719-9225333 Y Y ALL COVERAGE JL. JENDERAL SUDIRMAN KM. 3 RT.019 RW. 008 KEL. DESA LESUNG 054 4842 RS. UTAMA TANJUNG PANDAN 0719-9222211| 0719-9222212 Y Y ALL COVERAGE BATANG, KEC. TANJUNG PANDAN, KAB. BELITUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 055 1928 KLINIK UTAMA BELITUNG JL. MERDEKA NO. 27 TANJUNGPANDAN BELITUNG 0719-25526| 71925600 N Y RB,PHAR PANGKAL PINANG JL. JEND SUDIRMAN NO. 18, TAMAN BUNGA, GERUNGGANG, KEP BANGKA 056 5045 RSIA. MUHAYA 0717-436997| Y Y ALL COVERAGE BLITUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 057 2605 KLINIK & APOTEK KF 118 JL. A.YANI, P.PINANG 0717 436762| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 058 0900 SUN CLINIC EL-JOHN PLAZA, JL. HATTA, NO.208 0717-4297888-|- 0717-439488 N Y 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

Page 1 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 064 2389 KLINIK & RB CIGADING MEDIKA JL. RAYA ANYER KM.7 KUBANGSARI CIWANDAN CILEGON BANTEN 0254-311323| 0254-310568 Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 065 3158 KLINIK KELUARGA SURALAYA JL. CIRATA NOM 12 KOMPLEK PLTU SURALAYA (0254) 572100| - N Y RB,PHAR JL. RAYA MERAK KM.8 KESERANGAN KEL. RAWA ARUM KEC. GROGOL, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 066 4327 KLINIK ISNA MEDIKA 0254-573756| - N Y CILEGON, BANTEN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 067 0057 KLINIK ALFINA JL. RAYA SERANG RUKO PCI BLOK KK I NO 7-8 CILEGON 0254-383116| 0254-377377 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 068 3156 LAB. PRODIA CILEGON JL. SULTAN AGENG TIRTAYASA NO. 8, CILEGON - BANTEN 42414 0254-381990/398969| - N Y RB,PHAR PERUMAHAN GRIYA CILEGON BLOK D6-7 KEL.WARINGIN KURUNGI, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 069 2780 KLINIK GRIYA SEHAT 0254-388501| 0254-388501 N Y KEC.KRAMATWATU 42161 RB,PHAR 070 1254 RB & KLINIK AFINA JL. RAMBUTAN 12, PAGEBANGAN - CILEGON 0254-392568| 0254-392568 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 071 0129 APOTIK LABORA FARMA JL. ALUN-ALUN UTARA, NO.23 0254-391695| 0254-374278 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 072 0320 KLINIK BONA MEDIKA FESTIVAL RUKO BONA KARTA BLOK A31-32 CILEGON 0254-387684 / 0818769386| 0254-386699 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 073 0951 KLINIK & APOTEK KF 140 JL. S.A. TIRTAYASA NO 12 0254-399174 / 392278|- 0254-399174 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 075 1403 KLINIK KELUARGA PULO AMPEL JL. SALIRA INDAH DS.SUMURANJA PULOAMPEL 0254-5751100 / 0254 - 572100| 0254-5751100 N Y RB,PHAR APOTIK & KLINIK ANNISA SEHAT(D/H PRIMA 0254 - 399933/3998560254 - GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 076 0595 RUKO CILEGON CITY SQUARE ( SAMPING GIANT-PCI) BLOK B3;5 E3;5 0254-399928 N Y HUSADA) 391677|0254 - 391677 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 077 0302 KLINIK ANANDA CILEGON JL. R. SUPRAPTO KM.8 0254-310609| 0254-310821 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 078 1298 KLINIK IKHLAS MEDIKA IV KOMPLEK PONDOK CILEGON INDAH ( PCI ) BLOK A 19 NO.10 0254-395900/7061935/284937| - N Y RB,PHAR 0254-396333; 0254-372180; 0254- 079 0915 RS. KRAKATAU MEDIKA JL. SEMANG RAYA - CILEGON 0254-391972/374010 Y Y ALL COVERAGE 372123|0254-372123 KLINIK & APOTEK KF 268 PCI CILEGON (GROUP GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 080 1713 PONDOK CILEGON INDAH BLOK A4 NO.01CILEGON - BANTEN 0254-394827| 0254-376501 N Y 140) RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 081 1815 KLINIK INSAN PRIMA RUKO CILEGON CITY SQUARE BLOK I-8, CILEGON 0254-393 197| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 082 1943 KLINIK MUTIARA BUNDA JL. S.A TIRTAYASA NO. 86, CILEGON 0254-399968| 0254-399989/376454 N Y RB,PHAR PANDEGLANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 083 1764 KLINIK ALFURQON JL. RAYA LABUAN KM 2 TOROGONG MARGASANA - PANDEGLANG 0253-5808100| 0253-501313 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 084 0997 KLINIK DIFFA JL. RAYA LABUAN KM.12 CIPUTRI MENES 0253-502161-|- 0253-502160 N Y RB,PHAR RANGKASBITUNG

085 1084 RS. MISI LEBAK JL. MULTATULI NO.41 0252-201014-|- 0252-203390 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 086 3141 KLINIK DAN APOTEK MEDIKA JL. RANCASEMA - RANGKASBITUNG 0252-209975| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 087 0658 KLINIK SEHAT RABINZA JL. HADIWINANGUN, PERTOKOAN RABINZA, BLOK B1-2 0252-280023| 0252-280023 N Y RB,PHAR SERANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 088 0984 KLINIK CIJAWA MEDIKA JL. KH. A. FATAH HASAN NO.8 0254-204735 / 08128521336-|- 0254-204735 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 089 1009 KLINIK IKHLAS MEDIKA 2 JL. RAYA SERANG - JAKARTA KM.04 PAKUPATAN (DEPAN KAMPUS UNTIRTA) 0254-284937-|- - N Y RB,PHAR JALAN WARINGIN KURUNG RT 001/003 DESA SERDANG, KECAMATAN 090 5285 RSIA. PERMATA SERDANG 0254- 387515| 0254-387494 Y Y ALL COVERAGE KRAMATWATU KABUPATEN SERANG, BANTEN 42161 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 093 3985 KLINIK & APOTEK MURASAKI MEDIKA KOMP.PEJATEN MAS BLOK C/1 PEJATEN KEC.WATU-BANTEN 0254233317| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 094 2413 KLINIK ANDRI MEDISTRA JL. N. RAYA SERANG JAKARTA KM 8 CIRUAS, SERANG - BANTEN -| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 095 2392 KLINIK & APOTIK BONA MEDIKA SERANG JL. RAYA SERANG - CILEGON, LEGOK SUKMAJAYA RUKO NO.5A1 0254-228005/ 387684| 0254-205906/386699 N Y RB,PHAR KLINIK & APOTEK KF 472 SERANG BARU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 096 2608 JL. AHMAD YANI NO. 57,SERANG 0254 211065| - N Y (GROUP 140) RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 097 2726 KLINIK & APOTEK KF 253 (GROUP 140) JL. YUSUF MARTADILAGA NO. 114 SERANG- BANTEN 0254-211447| - N Y RB,PHAR JL. RAYA CILEGON KM.2 SABRNG RT.01/05, SERDANG KEC. KRAMATWATU, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 098 4236 KLINIK ALTIS (0254) 386325| - N Y SERANG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 099 2414 KLINIK JANNAH JL. KH.ABDUL HADI NO.13 KEBUN JAHE SERANG, KAB.BANTEN 0254-209321| - N Y RB,PHAR JL. GRIYA PURNAMA NO 99 TEGAL PADANG LEGOK, SERANG BANTEN 100 1414 RSIA. PURI GARCIA 0254-223333| 0254-223786; Y Y ALL COVERAGE 42162 101 1272 RS. SARI ASIH SERANG JL. JEND.SUDIRMAN, NO.38, PENANCANGAN, CIPOCOK 0254-220022| 0254-220345 Y Y ALL COVERAGE RS. HERMINA CIRUAS (D/H RS. CITRA MEDIKA 102 1489 JL. RAYA SERANG KM.9 DS.RANJENG - CIRUAS 0254-281829/ 0254-280555| 0254-281845 Y Y ALL COVERAGE CIRUAS GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 103 0115 KLINIK SERANG MEDIKA JL. RAYA SERANG CILEGON RUKO LEGOK SUKMAJAYA BLOK 5C NO.1 0254-223992| 0254-223992 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 104 1004 KLINIK WISATA MEDIKA JL. RAYA ANYER NO.9 0254-600933/605141/ 081905180805-|- 0254-605141 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 105 1008 KLINIK IKHLAS MEDIKA 1 KOMPLEK BUMI AGUNG PERMAI 1,NO. DI/6 0254-207918-|- 0254-281676 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 106 0937 KLINIK MODERN MEDIKA CIKANDE JL. RAYA SERANG KM.68 RUKO B6 CIKANDE SERANG 0254-400554-|- 0254-400556 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 107 0941 KLINIK MODERN MEDIKA KRAGILAN JL. RAYA SERANG KM15 RUKO D9 KRAGILAN 0254-281720-|- 0254-281720 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 108 1126 KLINIK KRAKATAU MEDIKA SERANG JL. TB SUWANDI, KAV KEMUNING NO. 1 LINGKAR SELATAN KEC SERANG 0254-204407| 0254-221397 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 110 1949 KLINIK & APOTEK KF 78 JL. A YANI NO 135 TANGERANG 021-5518433| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 111 0308 PAMULANG MEDICAL CENTER JL. RAYA PAMULANG BLOK D II NO.2, PAMULANG 021-740 5317| 021-7497624/7429156 N Y RB,PHAR 021-5380375/5388279021-5388279 / 112 0610 RSIA. PUTRA DALIMA GRIYA LOKA, SEKTOR 1.2, BLOK UA/26-27, BUMI SERPONG DAMAI 021-5381220 Y Y ALL COVERAGE 53741|021-5388279 / 53741 113 0007 RS. UIN SYARIF HIDAYATULLAH JL. IR. H. JUANDA, NO.95, CIPUTAT 021-30010100/7402718/7499129| 021-7493532 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 114 0062 KLINIK SARANA MEDIKA BARU JL. RAYA PERUMAHAN KOTA BUMI KP.TERITI DS.KARET.SEPATAN 021-5921153 / 02159372781| 021-59308529 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 116 0696 KLINIK DOKTER KELUARGA MAWAR JL. KARET RAYA, BLOK 7/69, PERUMNAS TANGERANG 021-5525633; 021-5913616|021-5913616 021-5913616 N Y RB,PHAR 117 0344 RS. QADR KOMPLEK ISLAMIC VILLAGE, KELAPA DUA 021-546 4466; 5463107; 5463106| 021-547 0775 Y Y ALL COVERAGE 021-5397314/ 53124105021- GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 118 0064 RB & KLINIK 24 JAM DIANA PERMATA MEDIKA JL. MH. THAMRIN, NO.87C 021-5394105/5312410 N Y 5395312|021-5395312 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 GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 120 0902 RB & KLINIK BUNDA MULYA (H UPEN) JL. SUMANTRI NO. 11 MEKAR MULYA PARUNG PANJANG 021-5978058-|- 021-5978058 Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 121 0912 KLINIK KARUNIA SEHAT RUKO CIKUPA BLOK B NO.21-23, DEPAN PERUM CITRA RAYA- CIKUPA 021-5963001-|- 021- 59408388 N Y RB,PHAR JLN. BOROBUDUR RAYA NO 152 PERUMNAS II BENCONGAN KELAPA DUA, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 122 0702 KLINIK MAHARANI 021-55654096/5919953| - N Y TANGERANG RB,PHAR 123 0285 RS. MELATI JL. MERDEKA, NO.92 TANGERANG 021-5523945/55776739| 021-55769914/5520028 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 124 0108 KLINIK PROVITA JL. IR.H.JUANDA NO.125 CIPUTAT 021-749 2619| 021-744 0085 N Y 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 021-552 2794; 021-5523239|021- 126 0022 RS. SARI ASIH KARAWACI JL. IMAM BONJOL NO.38 021-5525214 Y Y ALL COVERAGE 5523239 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 JL. HOS COKROAMINOTO (CILEDUG RAYA) NO.4A KREO SELATAN- 129 0859 RS. AMINAH TANGERANG 021-7371919/021-7371818|021-7371818 021-7371333 Y Y ALL COVERAGE LARANGAN GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 130 0872 RB & KLINIK MUTIARA OBBINI MEDIKA JL. RAYA KRESEK NO.27, DS.MERAK, BALARAJA 021- 59431110-|- 021-59430131 Y Y RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 131 1014 RB & KLINIK PERMATA - DR JAMILAH JL. NUSA INDAH I, BLOK A7 NO.1, PERUM. CIBODAS 021-5533314| 021-5533314 Y Y 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

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed 021- 133 0942 RSIA. MURNI ASIH JL. RAYA BOJONGNANGKA NO 86, MEDANG, PAGEDANGAN TANGERANG 021-54204504 Y Y ALL COVERAGE 36868757/5470263/54200982/546367202 021-5520692/71342783021- 134 1046 RSIA. PRATIWI JL. RHM NOERADJI, NO.42, KARAWACI 021-5224139 Y Y ALL COVERAGE 43933978|021-43933978 JL. RAYA SERPONG BSD SEKTOR IV,RUKO E.NO.43-45 SERPONG- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 135 1049 KLINIK SELARAS 021-5370311-|- 021-5377842 N Y TANGERANG 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 RS. AWAL BROS TANGERANG (D/H RS. GLOBAL 138 1116 JL. MH.THAMRIN NO.3 KEBON NANAS -CIKOKOL 021-55758888/55780888/55781234| 02155780480/55781545 Y Y ALL COVERAGE MEDIKA SUTERA NIAGA I NO. 21, RUKO ALAM SUTERA, SERPONG, TANGGERANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 139 2440 LAB. PRODIA TANGERANG 021-539 9961| 021-5312 2589 N Y 15325 RB,PHAR 140 2347 RS. PERMATA PAMULANG JL. RAYA SILIWANGI NO. 1 A, PAMULANG TANGERANG 021-74704999/74709079| 021 - 74709073 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 141 2609 KLINIK & APOTEK KF BERINGIN JL. BERINGIN RAYA NO.45, KARAWACI, TANGERANG 021 55763538| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 142 2469 KLINIK PRATAMA JL. CIRARAB RAYA NO.61 KEC. LEGOK TANGERANG - BANTEN 021- 54260359| - N Y RB,PHAR KOMP. BUMI JATI ELOK BLOK A I NO 7, JL. RAYA LEGOK-PARUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 143 1646 KLINIK JATI ELOK 021-98496234| 021-5977529 N Y PANJANG KM. 3,MALANGNENGAH, PAGEDANGAN, TANGERANG, BANTEN RB,PHAR JL. BHAYANGKARA 1 NO.68 KEL. PAKUJAYA, KEC. SERONG UTARA - 144 2774 RSIA. INSAN PERMATA 021-53121344| 021-5396733 Y Y ALL COVERAGE TANGERANG SELATAN 145 2744 RSIA. AQIDAH JL. RADEN FATAH NO.40 PARUNG SERAB, CILEDUG, TANGERANG 021 73450244, 7319025| 7310851 EXT.222 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 146 2807 KLINIK PERTAMEDIKA PONDOK RANJI JL. WR SUPRATMAN NO. 43 (KAMP UTAN) TANGERANG SELATAN 021-7355253| - N Y RB,PHAR JL. RUKO BARCELONA NO.23 PERUMAHAN PALEM SEMI KARAWACI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 147 3982 KLINIK & APOTEK KF PALEM SEMI 02129662588| N Y TANGGERANG RB,PHAR RUKO TAMAN PALMA JL. RAYA BOULEVARD BLOK G1 NO.25R CITRA RAYA- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 148 3983 KLINIK & APOTEK KF CITRA 02159409460| - N Y CIKUPA RB,PHAR SILOAM HOSPITALS LIPPO VILLAGE 149 0021 JL. SILOAM NO.6, LIPPO KARAWACI 1600 021-80646900| 021-5460921/546008 Y Y ALL COVERAGE (KARAWACI) 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 152 1082 KLINIK TIGA MANDIRI JL. CABE RAYA NO 68D PONDOK CABE, TANGERANG SELATAN 021-7426366-|- 021-7426414 N Y 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 GP,SP,OP,DENTAL,MAT,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 157 1547 KLINIK AMIRA GRIYA LOKA SEK 1.6 BLOK A1 NO.3 BSD, TANGERANG SELATAN 021-5384219| 021-53164795 N Y RB,PHAR 158 1324 RSIA. CINTA KASIH JL. CIPUTAT BARU RAYA NO.10 CIPUTAT 021 - 74706020 / 7424639| 021 - 74707986 Y Y ALL COVERAGE JL. WR SUPRATMAN NO.51 RENGAS CIPUTAT TIMUR, TANGERANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 159 1366 KLINIK KARTIKA 021-29053555,29053553| 021-73692937 N Y SELATAN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 160 1455 KLINIK PRADHANA RUKO PANORAMA NIAGA NO.14-15 JURUMUDI BARU BENDA 021-55767587| 2159308529 N Y RB,PHAR JL. PAHLAWAN SERIBU RAYA RUKO TOL BOULEVARD BLOK B NO.18.BSD GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 161 1459 KLINIK KARUNIA SEHAT II 021-53158045| 021-53158046 N Y CITY RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 162 1471 KLINIK MELIA MEDIKA KOMP. RUKO DUTA GARDEN SQUARE BLOK C NO 2, TANGERANG 021-51488219/54370568| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 163 1575 MOM & CHILD CARE CLINIC JL.RAYA KELAPA DUA RUKO PDA KAV.25-29 GADING SERPONG 021-54214848 / 083804104440| 021-54209393 N Y 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 021-5525564/021-557 91563|021-557 169 0017 RS. AN-NISA TANGERANG JL. , NO.96, KM.3, CIBODAS 021-55791563 Y Y ALL COVERAGE 91563 RS. PREMIER BINTARO (d/h 170 0412 JL. MH THAMRIN NO.1, SEKTOR 7, BINTARO JAYA 021-745 5500/27625500| 021-748 64854/745 58 Y Y ALL COVERAGE RS.INTERNASIONAL BINTARO) 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 175 1812 SMILE N SHINE DENTAL CARE CENTER ALAM SUTERA TOWN CENTER (ASTC) BLOK 10D NO.6 0816869191 / 021-29008540| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 176 1866 KLINIK SATELIT GSM BINTARO JL. BINTARO JAYA SEKTOR IX RUKO ELANG RAYA KAV.1 NO.10-11 021-7450818| 021-7450642 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 177 1947 KLINIK & APOTEK KF 219 JL. IR H JUANDA NO 111 SITUGINTUNG, CIPUTAT 021-7401868| - N Y RB,PHAR COMMERCIAL PARK CENTRAL BUSINESS OF DISTRICT BSD KAV.7 178 1810 RS. KHUSUS BEDAH THT PROKLAMASI BSD 021-29002929| 021-29002930 Y Y ALL COVERAGE TANGERANG SELATAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 179 1935 APOTIK FARMARIN IV BINTARO BINTARO UTAMA SEKTOR 3 BLOK AM, BINTARO JAYA 021-7357077| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 180 1948 KLINIK & APOTEK KF 115 JL. PAMULANG PERMAI RAYA NO D2/1A TANGERANG 021-7498708| - N Y 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 JL. KH. HASYIM ASHARI BABAKAN TANGERANG, RUKO MODERNLAND BLOK GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 184 1768 KLINIK SATELIT GSM TANGERANG 021-55748000| 021-4254816 N Y AR NO 19-20 RB,PHAR JL. HOS COKROAMINOTO PERUM PONDOK LESTARI BLOK C.1 NO.1-2 185 1985 RS. MEDIKA LESTARI 021-5854858| 021-7304150/021-7320 Y Y ALL COVERAGE CILEDUG 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 RUKAN VICTORIAN BINTARO BLOK AA NO.03, JL. BINTARO UTAMA SEKTOR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 189 6387 AUDY DENTAL BINTARO (021) 22734928 / 081382154488| - N Y 3A, PONDOK AREN, TANGERANG SELATAN RB,PHAR JL. RAYA KELAPA DUA PARAMOUNT SPARKS BLOK A NO. 18 KEC. KELAPA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 190 6389 J & J DENTAL CARE TANGERANG -| - N Y DUA TANGERANG RB,PHAR DENTAL PREMIER BINTARO ( D/H DENTAL 191 0955 JL. MH THAMRIN NO.1, SEKTOR 7, BINTARO JAYA 021-745 5500; 021-27625500 ext 1680|- 021-748 64854/745 58 N Y DENTAL INTERNASIONAL 021-55752575/5521270021- 192 0737 RS. USADA INSANI JL. KH HASYIM ASHARI NO.24 CIPONDOH, TANGERANG 021-55754335 Y Y ALL COVERAGE 55755665/5521272|021- 193 1619 RSIA. BUAH HATI PAMULANG JL. RAYA SILIWANGI NO 189 PONDOK BENDA PAMULANG 021-7421149 / 7414488| 021-7420322 Y Y ALL COVERAGE 021-29779999/85550711 - 353438|0711 - 194 0733 RS. OMNI ALAM SUTERA JL. ALAM SUTERA BOULEVARD KAV.25 SERPONG 021-5312 8666 Y Y ALL COVERAGE 353438 JL. LETNAN SUTOPO, RUKO GOLDEN MADRID BLOK B NO.1-2, BUMI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 195 2819 LAB. PRODIA BUMI SERPONG DAMAI (BSD) 021-53160403/4| 021-53160406 N Y SERPONG DAMAI RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 196 3791 RSIA. CITRA ANANDA JL. RE MARTADINATA NO. 30, CIPUTAT (021) 7401347/ 0852 1795 1795| (021) 7491701 Y Y 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 AREA PERKANTORAN GARUDA SENTRA OPERASI (GSO) GEDUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 198 1867 KLINIK SATELIT GSO CENGKARENG 021-25601565| 021-5501801 N Y POLIKLINIK GSM BANDARA SOEKARNO-HATTA CENGKARENG RB,PHAR JL. MAULANA HASANUDIN Gg.AMPERA II NO.7-8, PORIS GAGA, BATU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 199 6002 KLINIK & LAB BETH RAPHA AGAVE INSANI 021-5445855 / 68800855| 021-5445855 N Y CEPER RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 200 3978 KLINIK & APOTEK KF 447 CIRENDEU JL. CIRENDEU RAYA NO.27C CIPUTAT 021-7415997| -021-7415997 N Y RB,PHAR JL. RAYA LEGOK KM 7 DESA CIJANTRA KEC. LEGOK, KARAWACI, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 201 3999 KLINIK PESONA LEGOK 021-54220281| - N Y TANGERANG, BANTEN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 202 2337 KLINIK TUMBUR JL.PAHLAWAN NO.4 SITUGINTUNG REMPOA CIPUTAT TIMUR 0217492818| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 203 6457 KLINIK DARMA NUSANTARA JL. RAYA SERANG KM 9 BITUNG KADU CURUG 021- 5566316| - N Y RB,PHAR KEBAYORAN ARCADE III BLOK KA/E 1-22, JL. BOULEVARD BINTARO JAYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 204 4697 KLINIK ICHSAN BINTARO (021) 29521655| (021) 2952 1655 N Y SEKTOR 7/ BINTARO JAYA - TANGERANG SELATAN 15229 RB,PHAR 021-7333430/ 33553359021- 205 0936 RS. SARI ASIH CILEDUG JL. HOS COKROAMINOTO NO.38 CILEDUG 021-7333441 Y Y ALL COVERAGE 7332758|021-7332758 DISTRICT TIVOLLI NO.1 PARAMOUNT SERPONG, JL. BOULEVARD RAYA 206 1968 BETHSAIDA HOSPITAL 021-29309999| 021-29542637 / 39 Y Y ALL COVERAGE GADING SERPONG KAV.29 JL. BRINGIN RAYA NO. 3-4-5, KEL. NUSAJAYA, KEC. KARAWACI, 207 4695 RS. TIARA TANGERANG (021) 29238000| (021) 29237999 Y Y ALL COVERAGE TANGERANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 208 3532 CLINIC ICON 8 JL. HORISON BROADWAY BLOK M2 NO. 3 BSD CITY , TANGERANG (021) 33438000/ 021 94588000| (021) 68538820 N Y RB,PHAR JL. RAYA SERANG KM. 10 RT 001/RW 004 KEL. CURUNG DESA KADU. KAB. 209 4747 RS. HERMINA BITUNG 021-59497525| 021-59497690 Y Y ALL COVERAGE TANGERANG JL. RAYA KOSAMBI TIMUR RAYA NO. 2, RT. 011/ RW. 004, KEL. KOSAMBI 210 4657 RSIA. BUN (021) 70610735; 29031299| - Y Y ALL COVERAGE TIMUR, KEC. KOSAMBI, TANGERANG, BANTEN

Page 3 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed KOMP. RUKO W.S FAMILY, JL. GARUDA NO.10/3, KEL. BATU CEPER, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 211 4684 KLINIK ALFA (021) 95000408| - N Y TANGERANG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 212 3979 KLINIK & APOTEK KF 267 BINTARO JL. BINTARO UTAMA V BLOK EA 2 NO.35 BINTARO 021-7371018| - N Y RB,PHAR JL. RUKO KEBAYORAN ARCADE 2 SEKTOR 7, BLOK 33-35, BINTARO- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 213 2863 LAB. PRODIA BINTARO 021-7370185; 29511799| 021-29511798 N Y TANGERANG RB,PHAR RUKO PARAMOUNT CENTER 1A/ 32 JL. KELAPA DUA, GADING SERPONG, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 214 3701 PRODIA GADING SERPONG (021) 29014884, 29014885| - N Y TANGERANG 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 JL. MALEO RAYA BLOK . JE 8/9 BINTARO, PONDOK PUCUNG, PONDOK GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 216 4321 JAKARTA BOUTIQUE DENTAL CENTER (JBDC) 021 745 8195| - N Y AREN, TANGERANG SELATAN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 217 0772 MEDIPRO CLINIC PASAR KEMIS PERUM WISMA MAS, BLOK A1, NO.30-31, PASAR KEMIS, KUTA JAYA 021-59318964| 021-59318965 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 219 5550 FRIENDLY DENTAL CARE BSD RUKO BIDEX B16, BSD CITY, SERPONG 021-531164571, 08158939191| N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 222 2109 APOTEK KIMIA FARMA 220 BENGKULU JL. S. PARMAN BENGKULU -| - N Y RB,PHAR JL. FLAMBOYAN DESA GIRI KENCANA NO. 104 KETAHUN BENGKULU UTARA, 223 5415 KLINIK RAWAT INAP RAFAELA KENCANA (085268347777)| - N Y ALL COVERAGE BENTONG 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 226 2108 APOTEK KIMIA FARMA 72 BENGKULU JL. SUPRAPTO NO. 48 BENGKULU 0736-20601| 0736-20601 N Y 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 JL. MATARAMAN HERMINA RT 06 RW 50 GONDANGAN RINGINSARI 229 4334 RS. HERMINA YOGYA 0274-2800808/2800909| 0274-2800909 Y Y ALL COVERAGE MAGUWOHARJO, DEPOK 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 JL. RING ROAD UTARA NO. 17 A KARANGNANGKA RT 07 RW 13, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 233 4170 KLINIK PRATAMA DK 0274-4333679| 0274-4333679 N Y MAGUWOHARJO DEPOK SLEMAN 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 235 3986 KLINIK THC TIMOHO YOGYAKARTA JL. TIMOHO NO. 86 YOGYAKARTA 0274-5305079| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 238 3297 LAB. CITO YOGYAKARTA JL. ATMOSUKARTO NO. 4 KOTABARU YOGYAKARTA 0274 563656| - N Y RB,PHAR 239 2864 RS. AN NUR JL. N.COLOMBO, NO. 14, YOGYAKARTA 0274-585848/0274-514784| 0271-564110 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 240 2768 KIMIA FARMA 21 JL. MALIOBORO - YOGYA 0274 514980| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 241 2170 APOTEK FARMARIN YOGYAKARTA JL. P. MANGKUBUMI NO.73 YOGYAKARTA 0274-7822198| - N Y RB,PHAR 0274-586688/5622460274 -586688|0274 - 242 0077 RS. BETHESDA YOGYAKARTA JL. JEND.SUDIRMAN NO.70 0274-563312,521251 Y Y ALL COVERAGE 586688 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 243 2616 KIMIA FARMA 401 JL. SETURAN,C 3/B, JOGJA 0274 4332880| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 244 2617 KLINIK & APOTEK KF 275 JL. KALIURANG KM.6 NO.48 0274-886981/885220| 0274-886981 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 245 2618 KLINIK & APOTEK KF 70 JL. ADISUCIPTO 63A, JOGJAKARTA 0274 489135| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 246 2619 KLINIK & APOTEK KF 316 JL. PALAGAN, JOGJA 0274 869944| - N Y RB,PHAR JL. LAKSDA ADISUCIPTO N0. 32-34 DEMANGAN GONDOKUSUMAN 247 0991 SILOAM HOSPITALS YOGYAKARTA (0274) 4600 900|- (0274) 4600 922 Y Y ALL COVERAGE YOGYAKARTA 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 0274 2871840/ 620333/620373/0274- 250 0604 RS. LUDIRA HUSADA TAMA JL. WIRATAMA NO.4 TEGALREJO 55244 0274-589087 Y Y ALL COVERAGE 620091|0274-620091 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 251 2909 LAB. PRODIA BINTARAN YOGYAKARTA JL. BINTARAN KULON NO. 28 YOGYAKARTA 55151 0274-373271/375273| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 252 2908 LAB. PRODIA MANGKUBUMI YOGYAKARTA JL. PANGERAN MANGKUBUMI NO. 50 YOGYAKARTA 55232 0274-580675/515818| 0274-584911 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 253 4036 KLINIK KHADIJAH JL. PURWANGGAN NO. 45 0274-513357| 0274-513357 N Y 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 RUKAN PURI BOTANICAL RESIDENCE BLOK I 10 JL. JOGLO RAYA NO.51 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 255 6428 TOOTH AND TEETH DENTAL CLINIC 021-58900413 - 414| - N Y KEMBANGAN RB,PHAR 256 6249 RSUD TAMAN SARI JL. MADU NO.10 KEL MANGGA DUA KEC TAMANSARI JAKARTA BARAT 021-26564276| - Y Y ALL COVERAGE 021 - 530 5288, 534 7411,021 - 534 257 0204 RS. MEDIKA PERMATA HIJAU JL. RAYA KEBAYORAN LAMA, NO.64 021-53652856/5305291 Y Y ALL COVERAGE 741|021 - 534 741 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 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 Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 259 0771 KLINIK YADIKA TEGAL ALUR JL. KAMAL RAYA BLOK A7 NO.7-11 TEGAL ALUR 021-70605247 / 55351876| 021-55963484 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 262 0695 KLINIK KUSUMA I JL. PETA SELATAN, NO.50 kalideres 021-541 9747| 021-54360626 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 264 2640 KLINIK & APOTEK KF 254 JL. RAYA POS PENGUMBEN NO.11 JAKARTA BARAT 021 5349063| - N Y RB,PHAR 265 1102 RS. BHAKTI MULIA JL. AIPDA K.S.TUBUN, NO.79 021-5481625-|- 021-5331544 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 266 1127 JESSLYN MEDICAL CENTER PERUM.TAMAN SURYA III BLOK F/63 CENGKARENG 021-54365638| 021-54365638 N Y 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 021-5668284/5686404/5683053021-566 272 0109 RSAB. HARAPAN KITA JL. JEND S.PARMAN, KAV.87, SLIPI 021-5601816,5668285 Y Y ALL COVERAGE 8284|021-566 8284 273 0836 RS. ROYAL TARUMA JL. DAAN MOGOT NO.34 GROGOL 021-56967788/56958338|- 02156967756/56958589 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 274 0783 KLINIK MHT KALIDERES JL. PETA SELATAN A/2 KALIDERES, JAKARTA BARAT 021- 545602708| 021- 5456027 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 275 3977 KLINIK & APOTEK KF 282 JL. AIPDA KS TUBUN NO.84 B-C JAKARTA 081372756593| - N Y RB,PHAR KOMPLEK SENTRA NIAGA PURI INDAH BLOK T/6 NO.28, JL. PURI LINGKAR 276 3166 LAB. PRODIA PURI INDAH 021-58304501| N Y GP,LAB DALAM JAKARTA BARAT 277 4353 MITRA KELUARGA KALIDERES JL. PETA SELATAN NO. 1 RT 007/011 KALIDERES 021-22523700| 021-22523702 Y Y ALL COVERAGE RUKAN SIXTH AVENUE J01 A NO. 20-22, CITRA 6, KALIDERES, JAKARTA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 278 3211 GETHEALTHY CLINIC 021-29030041/42| 021-29030045 N Y BARAT RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 279 1945 KLINIK & APOTEK KF 96 JL. LET JEND S PARMAN KAV G/12, SLIPI, JAKARTA BARAT 021-5303347/57| - N Y RB,PHAR

Page 4 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

JL. CITRA 2 BLOK J 2 CITRA GARDEN CITY RT. 002/RW. 012 KEL. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 280 4770 KLINIK CIPUTRA CITRA GARDEN CITY 021-29038871-3| - N Y PEGADUNGAN KEC. KALIDERES, JAKARTA BARAT RB,PHAR 021- 25677888/021-5300889|021- 281 0101 SILOAM HOSPITALS KEBON JERUK JL. RAYA PERJUANGAN, KAV.8, KEBON JERUK 021-5321766 Y Y ALL COVERAGE 5300889 JL. MACAN KAV. 4-5 BLOK S16-S20, RT 010/001, KEL. KEDOYA UTARA KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 282 4492 KLINIK VIVA MEDIKA CENTRO CITY (021) 29666764 / 50200730| - N Y KEBON JERUK, JAKARTA BARAT RB,PHAR JL. PENYELESAIAN TOMANG IV KAVLING. DKI BLOK 95 NO. 1, MERUYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 283 4678 KLINIK BAMED 021 - 584 3456 / 584 46512| (021) 5867004 N Y UTARA - KEMBANGAN RB,PHAR -JL. KEDOYA AGAVE RAYA, PERKANTORAN TOMANG TOL RAYA BLOK A GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 284 3735 PRODIA KEDOYA (021) 5803066, 5812941| - N Y II/22, JAKARTA BARAT 11520 RB,PHAR JL. ARIES UTAMA BLOK E.1 NO. 1 N-M, KEL. MERUYA UTARA, KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 285 4679 KLINIK KL (021) 29415300| 021-29319150 N Y KEMBANGAN, JAKARTA BARAT RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 286 3601 PRODIA CIDENG JL. CIDENG BARAT NO. 36 A, JAKARTA PUSAT 10150 (021) 6321820| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 287 4514 PRODIA DAAN MOGOT BARU JL. TAMPAK SIRING BLOK KJG NO. 10 JAKARTA 021-54392150-29038204| - N Y RB,PHAR JL. TANJUNG DUREN RAYA GRAND SHOPPING ARCADE BEAUFORT 8 NO. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 288 4822 KLINIK MAYAPADA CENTRAL PARK (021) 29859901| - Y Y AC, KEL. TANJUNG DUREN SELATAN, KEC. GROGOL PETAMBURAN, JAKARTA RB,PHAR 021-5306901- 289 0018 RS. PELNI JL. AIP II K.S. TUBUN, NO.92-94, PETAMBURAN 0215483145/5306904/7 Y Y ALL COVERAGE 9/5349475/5460608/5484809021- JL. KEBON JERUK RAYA NO. 68 RT. 001 RW. 011 KEL. KEBON JERUK KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 290 5539 KLINIK TERATAI KEBON JERUK (021) 22534039| - N Y KEBON JERUK, JAKARTA BARAT RB,PHAR 291 0952 RS. PATRIA IKKT JL. CENDRAWASIH NO.1 KOMP DEPHAN/MABES TNI 021-5308981-84-|- 021-5346387 Y Y ALL COVERAGE JL. DURI RAYA NO. 22 KEL. DURI KEPA KEC. KEBON JERUK, JAKARTA 292 5078 RSIA. BINA SEHAT MANDIRI (021) 5669411/12 / 5658870| 021 5603531/5658870 Y Y ALL COVERAGE BARAT JL. BOULEVARD BLOK G-01/01 5 CITRA GERDEN CITY, KRL. PEGADUNGAN 293 4686 RS. CIPUTRA CITRA GARDEN CITY (021) 2255 7888| - Y Y ALL COVERAGE KEC. KALIDERES JAKARTA BARAT 11830 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 294 6382 AUDY DENTAL GREENVILLE JL RATU KEMUNING BLOK BK NO.6 GREENVILLE (021) 29401060 / 082211700082| - N Y RB,PHAR JAKARTA PUSAT GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 295 2637 KLINIK & APOTEK KF 2 JL. RAYA SENEN NO. 66 021 384-4788; 384-0742| - N Y RB,PHAR HOTEL INTERCONTINENTAL LG FLOOR R27-28, JL. JEND SUDIRMAN KAV.10- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 296 4238 MP DENTAL CENTER (021) 5735336| - N Y 11, KEL. KARET TENGSIN, KEC. TANAH ABANG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 297 2507 MITRASANA IHC KALBE CEMPAKA PUTIH JL. LETJEN SUPRAPTO KAV 4 CEMPAKA PUTIH, JAKARTA PUSAT 021-42873888 EXT : 1451| - N Y RB,PHAR 298 4228 RS. LADOKGI JL. FARMASI NO.1, TANAH ABANG, JAKARTA PUSAT (021) 573 3026| - Y Y ALL COVERAGE 021-384 0484, 3441008021-376134|021- 299 0788 RSPAD GATOT SUBROTO (PAV.KARTIKA) JL. ABDUL RACHMAN SALEH NO.24 021-3859460,3501308 Y Y ALL COVERAGE 376134 GEDUNG DATA SCRIPT LT.6 KAWASAN NIAGA SELATAN BLOK B-15, 300 4375 KLINIK MATA NUSANTARA (Kemayoran) (021) 654 6688| (021) 654 5208 N Y GP,OP KEMAYORAN GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 301 1837 E-LAB. S PERCETAKAN NEGARA JL. PERCETAKAN NEGARA NO 17 JAKARTA PUSAT -| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 302 4662 KLINIK & APOTEK KF PPBM BANK MANDIRI JL. RP. NO.2-4 CIKINI 021-2300 181| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 303 0397 KLINIK BARUNA JL. CIKINI RAYA NO.60 R/S 021-3141040-059| 021-3151065 N Y 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 JL. MH THAMRIN NO.8-9, ANZ SQUARE (UOB PLAZA) BASEMENT 1 UNIT C GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 306 1387 BRAWIJAYA CLINIC UOB 021-29261880| 021-29261890 N Y 1-3 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 021- 309 0787 RS. KHUSUS THT-BEDAH PROKLAMASI JL. PROKLAMASI NO.43 021- 3900947/3152548 Y Y ALL COVERAGE 3900002/3906893/3144795/3909783| (021) 31922005 / 3143215|(021) 310 0790 RSIA. BUNDA JAKARTA JL. TEUKU CIK DITIRO NO.28, MENTENG 021- 3928583,3928585 Y Y ALL COVERAGE 31922005 311 1115 RSPAD GATOT SUBROTO (PAV.IKA) JL. ABDUL RACHMAN SALEH NO.24 021-3504614| 021-3520643 Y N ALL COVERAGE H&S,GP,SP,OP,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 312 0802 SAHID SAHIRMAN MEMORIAL HOSPITAL JL. JEND.SUDIRMAN, NO.86 021- 57853911|021- 5727210 021- 57853922 Y Y RB,PHAR 313 0398 RS. MH. THAMRIN INTERNASIONAL JL. SALEMBA TENGAH, NO.26-28 021-3904422| 021-3926934,3926931 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 314 0705 KLINIK SWA INDOMEDIKA JL. JEND SUDIRMAN KAV 1, GD BNI 46 LANTAI BASEMENT 1 021-5728987| 021-5728990 N Y 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 021-3840484/3500004/021-376134|021- 316 1019 RSPAD GATOT SUBROTO (P.DARMAWAN) JL. ABDUL RACHMAN SALEH NO.24 021-3441903/3859460 Y Y ALL COVERAGE 376134 RS. HERMINA KEMAYORAN (d/h RSIA HERMINA JL. SELANGIT BLOK B.10, KAV. 4 KEL GUNUNG SAHARI, KEMAYORAN, 317 0392 021-22602525 WA 085694155353| - Y Y ALL COVERAGE PODOMORO) JAKARTA PUSAT THAMRIN CITY - OFFICE SUITE FLOOR 3 UNIT 2, JL. KH. MAS MASYUR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 318 2406 HENDRA HIDAYAT DENTAL CENTER (HHDC) 021-3199 7482| - N Y JAKARTA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 319 2636 KLINIK & APOTEK KF 1 JL. GARUDA NO.47, JAKPUS 021 424-5572| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 320 2794 KLINIK PERTAMEDIKA KANTOR PUSAT JL. PERWIRA 2 - 4 JAKARTA PUSAT 021-3816104/3815970/3815687| -- N Y RB,PHAR GEDUNG BANK INDONESIA JL. KEBON SIRIH NO 82 DAN 84 GEDUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 321 1406 APOTIK FARMARIN I KEBON SIRIH 021-29810000 / 29815268| 021-2311940 N Y KEBON SIRIH LT 1 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 325 1477 BUNDA INTERNASIONAL CLINIC JL. TEUKU CIK DITIRO NO.12, MENTENG 021-29186133.| 021-3926494 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 328 1612 LAB. KLINIK BIOTEST MENTENG JL. SUMATERA RT. 002 / 04, MENTENG 021-31937784| - N Y RB,PHAR INDOFOOD TOWER - PLAZA SUDIRMAN LT 8, JL. JEND SUDIRMAN KAV 76- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 329 1577 KLINIK MIRACLE ( GD INDOFOOD ) 021-57954537/38| 021-57954541 N Y 78 RB,PHAR 021-4250451/42801567021- 330 0953 RS. ISLAM JAKARTA (CEMPAKA PUTIH) JL. CEMPAKA PUTIH TENGAH I/1 021-4266546 Y Y ALL COVERAGE 42801567|021-42801567 331 1105 RS. JAKARTA EYE CENTER MENTENG JL. CIK DI TIRO 46, MENTENG 021-29221000/31935600|021-31935600 021-3904601 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 332 1709 KLINIK WISMA PT YPK MANDIRI WISMA MANDIRI LT I, JL. MH THAMRIN NO 5 021-39832805| 021-39832806 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 335 0793 KLINIK YES CARE JL. NO. 31C 021-3915487| 021-3146659 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 336 0789 KLINIK MHT SERDANG JL. H. UNG E - 71/2 KEMAYORAN 021-4249519| 021- 4249519 N Y RB,PHAR KOMPLEK RUKO RAWASARI MAS NO.B10 JL. PERCETAKAN NEGARA, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 337 2733 KINAN MEDICAL CENTER -| - N Y CEMPAKA PUTIH JAKARTA PUSAT RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 338 2735 THOMSON SPECIALIST CENTER JL. IMAM BONJOL NO.72, MENTENG JAKARTA PUSAT 10310 021-3910030| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 339 1633 KLINIK GARUDA SENTRA MEDIKA ( GSM ) JL. ANGKASA BLOK B.15 KAVLING 1, KEMAYORAN 021-4241000| 021-4254816 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 340 1232 KLINIK PRODIA HEALTH CARE KRAMAT JL. KRAMAT RAYA NO.150 021 - 3906709| 021- 3922721 N Y RB,PHAR SAHID SUDIRMAN RESIDENCE LT. 1 UNIT 1, JL. JEND. SUDIRMAN NO. 86 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 341 2405 HENDRA HIDAYAT IMPLANT CENTER 021-52970102/104| 021-52970205 N Y JAKARTA PUSAT 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 344 1700 FHL DENTAL CLINIC GEDUNG BRI II LT.15 SUITE 1509 JL. JEND SUDIRMAN NO 44-46 021-57851127/ 57930552| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 347 1495 APOTEK & KLINIK KF INDOSAT GD. INDOSAT LT.23 JL. MEDAN MERDEKA BARAT NO. 1 JAKARTA PUSAT 021-30003750| 021-30003750 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 348 3972 KLINIK MIRACLE GRAND INDONESIA MENARA BCA LT.9 JL. MH. THAMRIN, JAKARTA PUSAT (021) 23587188 EXT.10511| N Y RB,PHAR 021- 349 1026 RSIA. TAMBAK JL. TAMBAK,NO.18 MANGGARAI 021-3902550 Y Y ALL COVERAGE 2303444/087878218215/087880676072|- 350 1197 RSPAD GATOT SUBROTO (NON. PAV) JL. ABDUL RACHMAN SALEH NO.24 021-3448929| 021-3448929 Y N ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 351 4804 KLINIK ASHA JL. JOHAR NO. 1A MENTENG, JAKARTA PUSAT (021) 3905035 / 3905037/ 2305326| (021) 3928907 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 352 4058 KLINIK GRAHA PT YPK MANDIRI GEDUNG GRAHA MANDIRI LT.1 LOBBY SELATAN,JL. IMAM BONJOL NO.61 021 - 39838556| - N Y RB,PHAR 021-5732241/5741828021-5741828|021- 353 0084 RS. JAKARTA JL. GARNISUN NO.1 JEND. SUDIRMAN, KAV.49 021-5719870 Y Y ALL COVERAGE 5741828 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 354 2793 KLINIK PERTAMEDIKA KWARNAS JL. MEDAN MERDEKA TIMUR NO. 6 JAKARTA PUSAT 021-3502150 EXT 1998| - N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 356 0401 KLINIK SPESIALIS & APOTIK, RSB. ESTI JL. BANGKA RAYA, NO.28-30, PELA MAMPANG 021-7194434-35| 021-71791917 Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 357 0892 KLINIK FAMILY DENTISTRY JL. PANGLIMA POLIM II/2 021-7267267-021 7221266|- 021 7264365 N Y RB,PHAR 021-5251207 / 021-5205000|021- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 358 0911 KLINIK MEDIKA PLAZA KARTIKA CANDRA KARTIKA CHANDRA HOTEL, JL. JEND GATOT SOEBROTO KAV 18-20 021-5265921 N Y 5205000 RB,PHAR RDTX TOWER GROUND & 2 ND FLOOR. JL. PROF.DR.SATRIO KAV. E IV NO.6 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 359 0400 MEDIKALOKA HEALTHCARE CENTER 021-5261118| 021-5261119 N Y MEGA KUNINGAN, JAKARTA SELATAN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 360 2138 KLINIK PERTAMEDIKA PATRA JASA PATRA JASA OFFICE TOWER, JL. JEND. GATOT SUBROTO KAV.32-34 021-5228026/ 5217318| - N Y RB,PHAR JL. SINABUNG II NO. 32 AF KEL. GUNUNG KEC. KEB. BARU JAKARTA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 361 2139 KLINIK PERTAMEDIKA SINABUNG 021-7243262/7243282| 021-72800985 N Y SELATAN RB,PHAR BRAWIJAYA CLINIC & LIFE STYLE @ OKTROI OKTROI PLAZA, MEDICAL MEZZANINE LT. 3 JL. KEMANG UTARA RAYA NO. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 362 2229 021 - 7197580/ 71792101| 021 - 71792074 N Y KEMANG 1 JAKARTA SELATAN RB,PHAR 363 2443 BALI DENTAL CARE JL. PAKUBUWONO VI NO.111 JAKARTA SELATAN (021) 7223391/ 7223391| - N Y DENTAL JL. CILANDAK KKO NO.45A, RAGUNAN, PASAR MINGGU, JAKARTA SELATAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 364 2341 KLINIK AJI WARAS CILANDAK (021) 78836308; 78835703| - N Y 12550 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 365 2641 KLINIK & APOTEK KF 42 JL. ST. HASANUDDIN NO.1 KEBAYORAN BARU JAKARTA SELATAN 021 7220292| - N Y 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 GED. BINASENTRA KOMP. BIDAKARA JL. GATOT SOEBROTO KAV. 71 - 73 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 368 1412 APOTIK FARMARIN III BIDAKARA 021 - 83785219| 021 - 83793006 N Y JAKARTA RB,PHAR 369 1424 RSIA. ASIH JL. PANGLIMA POLIM I NO.34 JAKARTA SELATAN 12160 021-2700609-10| 021-7255181 Y Y ALL COVERAGE 021-5256228/5203866021-5203866|021- 370 1083 RS. MATA AINI JL. H.R. (KUNINGAN) JAKARTA 021-5224288/52964781 Y Y ALL COVERAGE 5203866 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 371 1546 KLINIK NDH (RAJA SERVICE) JL. RADIO DALAM RAYA, NO.54A 021-7257244| 021-7257244 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 372 1461 ALL CARE DENTAL CENTRE PLAZA 5 BLOK B NO.15 JL. MARGAGUNA PONDOK INDAH 72788688| 72788687 N Y RB,PHAR 021-7243366/7208192/7208192|021- 373 1089 RS. KHUSUS THT & BEDAH CIRANJANG JL. CIRANJANG NO.20-22 KEBAYORAN BARU 021-7264038 Y Y ALL COVERAGE 7208192 MENARA KUNINGAN,JL. HR. RASUNA SAID BLOCK X-7 LT1. UNIT I, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 374 1554 H2E DENTAL CLINIC 021-30040151/152| 021-30040152 N Y KUNINGAN RB,PHAR GEDUNG MENARA MULIA, LG-SUITE 018, JL. JEND.GATOT SUBROTO KAV.9- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 375 1458 MULIA HEALTH AND DENTAL CARE (MHDC) 021-5223838| 021-52901073 N Y 11 RB,PHAR 376 0799 RS. GANDARIA JL. GANDARIA TENGAH II, NO.12-14, KEBAYORAN BARU 021- 7250718/ 7203311| 021- 7222038 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 377 0800 KLINIK TRIAZ PERSADA GRAHA CIMB NIAGA TOWER LT.B1, JL. JEND. SUDIRMAN KAV.58 021- 2505770 / 2505250| N Y RB,PHAR 021-8292672/8311722021-8311722|021- 378 0193 RSIA. BUDHI JAYA JL. DR. SAHARJO, NO.120 021-8301901 Y Y ALL COVERAGE 8311722 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 379 0890 KLINIK INTERMED HEALTH & BEAUTY JL. KEBAGUSAN 1 NO. 8 JAKARTA SELATAN 021-7823501| 021-7823502 N Y RB,PHAR 380 1744 PARAHITA DIAGNOSTIC CENTER MAMPANG JL. WARUNG BUNCIT RAYA NO 150 MAMPANG JAKSEL 021-7949624| 021-7992719 N Y LAB GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 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 Y RB,PHAR 0218294955,8305768/9,8282795,837942 383 0041 RS. AGUNG JL. SULTAN AGUNG, NO.67, PASAR RUMPUT 021-8305791 Y Y ALL COVERAGE 07| 384 0043 RS. JAKARTA MEDICAL CENTER JL. BUNCIT RAYA, NO.15 021-7980888/7985177 - 7940836/37| 021-7940838 Y Y ALL COVERAGE MENARA KADIN INDONESIA, 27TH FLOOR, JL. H.R. RASUNA SAID, BLOK X- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 385 0199 MEDICARE CLINIC 021-57903905| 021-5274754 N Y 5, KAV.2-3 RB,PHAR GED. WTC II LOWER GROUND FLOURJL. JEND SUDIRMAN KAV. 29 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 386 2800 KLINIK PERTAMEDIKA JAKARTA LAND (WTC) 021-29522610| 021-29522611 N Y JAKARTA SELATAN RB,PHAR JL. KARANG TENGAH RAYA NO.60, LEBAK BULUS, CILANDAK, JAKARTA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 387 2954 KLINIK AJI WARAS KARANG TENGAH (021) 75909473| - N Y SELATAN 12440 RB,PHAR JL. RAYA TANJUNG BARAT NO. 111 RT/RW 007/004, KEL. TANJUNG BARAT, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 388 3326 KLINIK PERMATA MEDIKA 021-7821817| 021-7828489 N Y KEC. JAGAKARSA, JAKARTA SELATAN RB,PHAR KLINIK PERTAMEDIKA TUGU (pmc dental spa & GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 389 2140 WISMA TUGU JL. HR. RASUNA SAID KAV. C8-9. 021-5200340| - N Y clinic) RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 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 Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 391 3710 THOMSON EXECUTIVE HEALTH CENTER TALAVERA SUITE, JL. TB.SIMATUPANG KAV. 22-26 JAKARTA SELATAN (021) 7592 5268| (021) 7592 5269 N Y RB,PHAR 392 1488 RS. ASRI JL. DUREN TIGA RAYA, NO.20 021 27837900 / 021-7995566,7992211| 02179198118/79198733 Y Y ALL COVERAGE GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 393 2874 LAB. PRODIA KEBAYORAN JL. GUNAWARMAN NO. 77, KEBAYORAN BARU 021-7220203| 021-7226450 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 394 2797 KLINIK PERTAMEDIKA PHE PHE TOWER LT. 2 JL. TB SIMATUPANG KAV. 99 021-29547300| - N Y RB,PHAR EPIWALK OFFICE SUITES LT. 3 UNIT B 316-317 KOMPLEK RASUNA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 395 4340 KLINIK EPICENTRUM MEDICAL CENTER (021) 2991 2383| (021) 2991 2393 N Y EPICENTRUM, JL. H.R RASUNA SAID KEL. KARET KUNINGAN KEC. RB,PHAR LOTTE SHOPPING AVENUE FLOOR 5 CIPUTRA WORLD 1, JL. PROF. DR. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 396 4413 KLINIK UTAMA CIPUTRA MEDICAL CENTER 021-29888137| - N Y SATRIO KAV. 3-5, KEL. KARET KEC. SETIABUDI, JAKARTA SELATAN RB,PHAR KUNINGAN CITY MALL B-C -D, JL. PROF SATRIO KAV. 18, JAKARTA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 397 4414 AIC - MEDICAL IMAGING DIAGNOSTIC CENTER (021) 3005 1801/02| (021) 30051803 N Y SELATAN 12940 RB,PHAR MRCCC-SILOAM HOSPITALS SEMANGGI (D/H JL. GARNISUN 2-3 KARET, SEMANGGI SETIABUDI (BELAKANG UNIV. 398 1066 021-29962888/800/788| 021-29962778 Y Y ALL COVERAGE SPECIALIST C ATMAJAYA ) JAK- SEL GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 399 1752 LAB. KLINIK BIOTEST WIJAYA JL. WIJAYA I NO 58, KEBAYORAN BARU, JAK-SEL 021-7232445| 021-7268711 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 400 1872 KLINIK TRIHATI PLUS RUKAN ROYAL PALACE BLOK A5, JL. PROF DR SH NO 1 021-829 9119| 021-8299113 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 401 1838 E-LAB. S JL. GATOT SUBROTO JL. GATOT SUBROTO KAV 52 JAKARTA SELATAN -| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 402 1942 KLINIK & APOTEK KF 47 JL. RADIO DALAM RAYA 1-5, JAKARTA SELATAN 021-7208735| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 403 1944 KLINIK & APOTEK KF 152 JL. RAYA PASAR MINGGU KM 18 JAKARTA SELATAN 0217943222| 021-7943223 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 404 1936 APOTIK FARMARIN VI RASAMALA WISMA PPBI JL. RASAMALA NO.2 PANCORAN 021-8290073| 021-83794460 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 405 2033 KLINIK NAMIRA JL. JATIPADANG RAYA NO. 62 PASAR MINGGU 021-7820645/78830676| 021-7820645 N Y RB,PHAR 021-27545454/27545400/021- 406 0228 RSIA. KEMANG MEDICAL CARE JL. AMPERA RAYA, NO.34,KEMANG 021-78843548 Y Y ALL COVERAGE 6317288|021-6317288 JL. WARUNG SILA no. 8 RT. 006 RW. 04 GUDANG BARU, CIGANJUR, (021)7874612; 7863408; 78887087; 407 4210 RSIA. ANDHIKA (021) 7874612 Y Y ALL COVERAGE JAGAKARSA, JAKARTA SELATAN 7863408| PASIFC PLACE MALL, B1-01, JL. JEND SUDIRMAN KAV 52-53 SCBD, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 408 3711 THOMSON MEDICAL CLINIC (021) 5797 3497| (021) 5797 3496 N Y JAKARTA SELATAN RB,PHAR 021-7229623/7250243/7208358|021- 409 0999 RSU. MUHAMMADIYAH TAMAN PURING JL. GANDARIA I NO.20 KEBAYORAN BARU 021-7234823/7210516 Y Y ALL COVERAGE 7208358 410 0797 RS. MEDISTRA JL. GATOT SUBROTO KAV.49 021-5210200 /| 021-5210184/5 Y Y ALL COVERAGE JL. RS. NO. 27 A, RT.001 RW.006 KEL. GANDARIA SELATAN, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 411 3974 LAB. CITO JAKARTA (021) 766 4036| (021) 766 3640 N Y CILANDAK, JAKSEL RB,PHAR GEDUNG CITY PLAZA LT P9, JL. GATOT SUBROTO 42 (KAWASAN WISMA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 412 1836 AIS HEALTHCARE 021-29305480| - N Y MULIA) RB,PHAR JL. CIPETE RAYA NO. 16 BLOK A-7 RT.006/RW.004, KEL. CIPETE SELATAN, 413 4525 ALEA DENTAL CLINIC (021) 75915723| - N Y DENTAL CILANDAK, JAKARTA SELATAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 414 2931 APOTEK KIMIA FARMA DUREN TIGA PLN PUSLITBANG JL. DUREN TIGA NO 102 JAKARTA 12760 -| - N Y RB,PHAR 415 0049 RS. PONDOK INDAH JL. METRO DUTA, KAV. UE, PONDOK INDAH 021-7657525| 021-7502324 Y Y ALL COVERAGE JL. PALAPA I NO. 4 KOMPLEK PERTANIAN PASAR MINGGU JAKARTA 416 2379 KLINIK PRATAMA PALAPA DENTISTS 021-7806291| 021- 7806291 N Y DENTAL SELATAN 12520 JL. KH ABDULLAH SYAFEI NO. 28KEBON BARU, TEBET JAKARTA SELATAN, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 417 3736 PRODIA KAMPUNG MELAYU (021) 8308055, 8304268| - N Y 12830 RB,PHAR JL. TEBET BARAT VII NO. 49 RT. 004 RW. 004, KEL. TEBET BARAT KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 418 4820 TIDI DENTAL CLINIC (021) 8300050| - N Y TEBET, JAKARTA SELATAN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 419 4858 KLINIK YEMIMA MEDICAL CENTER JL. RAYA LENTENG AGUNG KEC. JAGAKARSA, JAKARTA SELATAN (021) 29050669| - N Y RB,PHAR RUKO BONA INDAH BLOK A2/ KAV. C7, JL. KARANG TENGAH RAYA LEBAK GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 420 3571 PRODIA BONA INDAH 021-7506715| N Y BULUS, JAKARTA 12440 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 421 2919 LAB. PRODIA PASAR MINGGU JL. RAYA PASAR MINGGU/ 98E, JAKARTA SELATAN 021-7986247/7901922/79184723| 021-7901922 N Y RB,PHAR PLN P3B JB KRUKUT-LIMO, CINERE 16514, KOTAK POS 159 CINERE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 422 2932 APOTEK KF55 CINERE 021 7220292| N Y JAKARTA SELATAN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 423 6431 TEBET DENTAL CLINIC JL. TEBET BARAT 8/18 KEL. TEBET BARAT, KEC. TEBET, JAKARTA SELATAN (021) 8308221/ 8306244| (021) 8202983 N Y RB,PHAR JL. CILEDUG RAYA NO. 94-96, KEL. CIPULIR KEC. KEBAYORAN LAMA, 424 6081 RSIA. CILEDUG (021) 7245646/ 7207828| (021) 72792194 Y Y ALL COVERAGE JAKARTA SELATAN APARTEMEN TAMAN SARI SEMANGGI TOWER A UNIT GF.15 JL.AKRI NO.134 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 425 5592 KLINIK THAMRIN TAMAN SARI (021) 29888506| N Y RT.008/002, KARET SEMANGGI, SETIABUDI RB,PHAR MAYAPADA HOSPITAL JAKARTA SELATAN 426 2356 JL. LEBAK BULUS I KAV.29 021-29536660 / 29208505 / 29217777| 021-29216666 Y Y ALL COVERAGE (MHJS) GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 427 5413 KLINIK ROYAL HEALTH CARE JL. BUNCIT RAYA NO.99 KALIBATA, PANCORAN 021-7940015 / 0811935249| N Y RB,PHAR 021- 428 0796 RS. METROPOLITAN MEDICAL CENTRE (MMC) JL. HR. RASUNA SAID, KAV. C21, KUNINGAN 021-5226070/5227060 Y Y ALL COVERAGE 5203435/0811865958/081617106696| GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 429 4234 RAYS INTERNATIONAL DENTAL CLINIC JL. BRAWIJAYA VIII NO. 2, JAKARTA SELATAN 021-7262347| 021-7225844 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 430 3989 KLINIK & APOTEK KF NO. 55 KEBAYORAN JL. KEBAYORAN LAMA NO. 34K JAKARTA SELATAN 021-7226444/7203563| 021-7203563 N Y RB,PHAR JL. CIPETE NO. 3 RT/RW 014/003, KEL. CIPETE SELATAN, KEC. CILANDAK, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 431 4640 KLINIK MOESLICHAN (021) 7657861| (021) 75904535 N Y JAKARTA SELATAN RB,PHAR LOTTE SHOPPING AVENUE FLOOR 5 CIPUTRA WORLD 1, JL. PROF. DR. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 432 4488 KLINIK UTAMA CIPUTRA SMG EYE CLINIC (021) 29888138| - N Y SATRIO KAV. 3-5, KEL. KARET KEC. SETIABUDI, JAKARTA SELATAN RB,PHAR KAWASAN PERKANTORAN ASS. ASTRA, JL. TB SIMATUPANG KAV.15 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 433 2798 INHOUSE KLINIK PERTAMEDIKA GARDA OTO 021-75918577| - N Y JAKSEL RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 434 0597 KLINIK JMC DHARMA BHAKTI JL. CILANDAK KKO RAYA NO.45 021-781 9848 / 0217989123| - N Y RB,PHAR

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed Bellezza Shopping Arcade Lt.2 Unit 30&31 Jl.Letjen Soepeno No.34 Arteri GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 435 0758 DE BLITZR DENTAL CARE 021-25675742| 021-25675743 N Y Permata Hijau JKT SELATAN 12210 RB,PHAR ARTERI PONDOK INDAH, JL. SULTAN NO. 31 C, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 436 2820 LAB. PRODIA ARTERI (021) 7227728, 7226655, 7291710| - N Y KEBAYORAN LAMA, JAKARTA SELATAN 12240 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 437 5904 BIC CLINIC BUNDA PACIFIC PLACE PACIFIC PLACE, LEVEL B1 - 17A, JL. JEND.SUDIRMAN KAV.52-53 021-57973781/93| N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 439 2086 KLINIK GLOBAL DOCTOR JLN. WARUNG JATI BARAT NO. 98, LOT 7-9, PEJATEN 021-7194565/ 7980183| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 440 1076 KLINIK YADIKA PETUKANGAN JL. DAMAI RAYA NO.1 PETUKANGAN SELATAN - JAKARTA SELATAN 021-7370881|- 021-73887810 N Y 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 EPPIWALK OFFICE SUITES LT. 6 UNIT B 629, JL. H.R. RASUNA SAID KEL. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 443 3540 FHL DENTAL CLINIC EPPIWALK OFFICE 021-29912232| - N Y KARET KUNINGAN KEC. SETIABUDI 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 GD. MAYAPADA TOWER II LT.2, JL.JEND.SUDIRMAN KAV.27, KARET, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 445 4707 KLINIK MAYAPADA (021) 29859988 / 29859999 ext. 806| - N Y SETIABUDI RB,PHAR KOMP.EPICENTRUM RASUNA, EPICENTRUM WALK OFFICE SUITE LT.3 UNIT GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 446 5428 GOOD DOCTORS MEDICAL CENTER 021-29912131 - 32 / 29941137| 021-29941137 N Y A 310-311 RB,PHAR PLAZA OLEOS, JL.TB SIMATUPANG KAV.53A LG UNIT B, KEL.KEBAGUSAN, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 447 5429 KLINIK UTAMA INDO MEDIKA INTERNATIONAL 021-22780121 / 19| 021-22780120 N Y KEC.PASAR MINGGU RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 448 6380 AUDY DENTAL KEMANG JL BANGKA RAYA NO.40E KEMANG (021) 71794428 / 082122324969| - N Y RB,PHAR JL. RADIO DALAM RAYA NO. 9A RT/RW 008/002 KEL GANDARIA KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 449 6388 J & J DENTAL CARE RADIO DALAM 021-7207877| - N Y KEABYORAN BARU JAKARTA SELATAN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 450 6227 MEDIKA PLAZA WTC 2 CLINIC WTC 2 LOWER GROUND FLOOR JL. JEND. SUDIRMAN KAV 29 021-29522611| 021-29522610 N Y RB,PHAR BELTWAY OFFICE PARK , GD ANNEX LT. 1 JL. AMPERA RAYA NO. 9-10, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 451 6483 KLINIK MEDIKA PLAZA BELTWAY (021) 30027070| - N Y RAGUNAN PASAR MINGGU 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 JL.KEBAGUSAN I NO.4, RT002/01 (KOPINDOSAT), KEBAGUSAN, PASAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 453 5789 KLINIK UTAMA CONFIDENTA CLINIC 021-22780426| N Y MINGGU RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 454 6381 AUDY DENTAL CIPETE JL. CIPETE RAYA NO.55, CIPETE (021) 29124856 / 085775006872| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 456 5808 CLINIC 18 GEDUNG 18 OFFICE PARK KAV.18 LANTAI MEZZANINE.M2, KEBAGUSAN 083871523455| N Y RB,PHAR 021-78888723/7872210/78888721021- 457 0854 RS. ZAHIRAH JL. SIRSAK NO.21, JAGAKARSA 021-7270013/7872210 Y Y ALL COVERAGE 78888723|021-78888723 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 458 0112 SUDIRMAN MEDICAL CENTER JL. SETIABUDI TENGAH NO.18 021-5203467| 021-5203468 N Y RB,PHAR 459 0795 RS. PUSAT PERTAMINA JL. KYAI MAJA 43, KEBAYORAN BARU (021) 7219555; 7219800| (021) 7203540, Y Y ALL COVERAGE 021-7501192/7504669/75901174021 - 460 0395 RS. PRIKASIH JL. RS. FATMAWATI, NO.74, PONDOK LAB. U - CILANDAK 021-7505148 Y Y ALL COVERAGE 7504669|021 - 7504669 461 0879 RSU. YADIKA CIPUTAT JL. CIPUTAT RAYA, NO.5, KEBAYORAN LAMA 021-7291074| 021-72895046 Y Y ALL COVERAGE GEDUNG BINA SENTRA, LT.DASAR, KOMP.BIDAKARA, KAV.71-73, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 462 1408 BIDAKARA MEDICAL CENTER (BIMC) 021-83783535/83783636| 021-83785349 N Y PANCORAN RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 463 6231 OMDC DENTAL CLINIC JL. WARUNG BUNCIT RAYA NO.6A 021-79196767| - N Y RB,PHAR JAKARTA TIMUR RS. KHUSUS MATA SMEC (SUMATERA EYE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 464 3531 JL. PEMUDA NO.36, RAWAMANGUN (021) 4714848| (021) 4755703 N Y CENTER) JAKARTA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 465 5899 KLINIK UTAMA ASSHOMADIYAH JL. AL.BAIDHO RAYA NO.2A KEL.LUBANG BUAYA, KEC.CIPAYUNG 021-8779 6464| 021-8779 1956 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 466 6011 KLINIK ZAFIRA MEDIKA KAYUMANIS JL. KAYUMANIS TIMUR NO.37 RT 014 RW 002, KAYUMANIS, MATRAMAN 021-85911696| N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 468 6385 AUDY DENTAL PONDOK BAMBU JL. PAHLAWAN REVOLUSI NO.15 PONDOK BAMBU (021) 29622453 / 081298813800| - N Y RB,PHAR 021-8617212/3 ; 021-8617213|021- 469 0749 RS. HARUM SISMA MEDIKA JL. TARUM BARAT, KALIMALANG JAKTIM 021-8601030 Y Y ALL COVERAGE 8617213 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 GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 472 0652 RB & KLINIK AL - FAUZAN JL. RAYA CONDET NO.13, BALEKAMBANG CONDET 021-80886224| 021-8096968 Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 473 1139 KLINIK TJAKRA JL. RAYA BOGOR, KM.24, NO.35, SUSUKAN CIRACAS 021-8779 4539 / 8401677| 021-87794558/8401677 N Y RB,PHAR JL. PONDOK BAMBU BATAS NO. 14 RT. 003 RW. 02, KEL.PONDOK BAMBU, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 474 5540 KLINIK TERATAI PONDOK BAMBU (021) 29361827| - N Y KEC. DUREN SAWIT, JAKARTA TIMUR RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 475 1933 APOTIK FARMARIN II PENGGILINGAN PERUM TAMAN PULO INDAH BLOK I NO.7-8 PENGGILINGAN CAKUNG 021-4800688| - N Y RB,PHAR 476 0060 RS. HARAPAN BUNDA JL. RAYA BOGOR KM.22 NO.44 021-8400257| 021-8412977/87780201 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 477 4157 KLINIK CEMPAKA JL. RAYA PULAU GEBANG NO. 86 RT 06 RW 06, CAKUNG 021- 480 1980| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 478 2142 KLINIK PERTAMEDIKA RAWAMANGUN JL. MUNDU RAYA NO.1 JAKARTA TIMUR 021-4894150| 021-4894278 N Y RB,PHAR 479 1244 RS. MASMITRA JL. KELURAHAN JATIMAKMUR, NO.40, PONDOK GEDE 021-84971766| 021-8483047 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 480 3533 KLINIK MEDIKA PRAKARSA (MEDSA) JL. RADEN INTEN II NO.31 DUREN SAWIT (021) 86908103| 021-86908105 N Y 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 021- 482 0102 RS. ISLAM JAKARTA TIMUR (PONDOK KOPI) JL. RAYA PONDOK KOPI 021-8611101/86604256 Y Y ALL COVERAGE 8630654/29809000/8610471/8610471|02 GD. ALHIJAZ, JL. 293A, CAWANG, KEC. KRAMAT JATI, 483 4376 KLINIK MATA NUSANTARA (DEWI SARTIKA) (021) 8087 8833| (021) 8087 7474 N Y GP,OP JAKARTA TIMUR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 484 2464 MITRASANA PT JL. PULOGADUNG RAYA KAV.23 RT.010/09, JATINEGARA, CAKUNG 021-29634912 / 89835394| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 487 2643 KLINIK & APOTEK KF 49 JL. P. REVOLUSI 53, PD. BAMBU, JAKARTA TIMUR 021 861-5154| 021-8612721 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 488 3980 KLINIK & APOTEK KF 48 JL. MATRAMAN RAYA NO 55 JAKARTA TIMUR 0818810414| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 489 3981 KLINIK & APOTEK KF LAP.TEMBAK JL. LAWU B1 NO.1 CIBUBUR LAPANGAN TEMBAK CIBUBUR 08128737346| - N Y RB,PHAR BPRI CENTER GED. B, JL. RAYA TENGAH NO.26 GEDONG, PASAR REBO, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 490 4356 KLINIK BUDHI PRATAMA (021) 87783668| (021) 87782670 N Y JAKARTA TIMUR RB,PHAR RSIA. AL-FAUZAN (JAKARTA ISLAMIC 491 1868 JL. PEDATI NO 3 RT 5 RW 7, KAMPUNG TENGAH KRAMAT JATI 021-87780318| - Y Y ALL COVERAGE HOSPITAL) 492 1907 RSIA. SAMMARIE BASRA JL. BASUKI RACHMAT NO. 31, PONDOK BAMBU, DUREN SAWIT 021-86613145| 021-86613147 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 493 1932 APOTEK KIMIA FARMA 193 JL. UTAN KAYU NO 105 P JAKARTA TIMUR 021-8520808| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 495 2141 KLINIK PERTAMEDIKA MEDAN SATRIA JL. ARUN IX NO. 2 MEDAN SATRIA CAKUNG JAKARTA TIMUR 17132 021-4604944| N Y RB,PHAR 496 2391 RS. JANTUNG JAKARTA JL. MATRAMAN RAYA NO.23, JAKARTA TIMUR 021-29361158/29361160/29360698| 2129361158 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 497 2375 KLINIK NAMIERA JL. KELAPA DUA WETAN PERUM PTB BLOK 2C NO 10 021-8725774| 021-8725774 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 498 2620 KLINIK & APOTEK KF 4 JL. PERSERIKATAN 7-8, RAWAMANGUN 021 471-8059| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 499 2638 KLINIK & APOTEK KF 147 JL. DUREN SAWIT 021 861-5458| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 500 0962 KLINIK CONDET JAYA JL. CONDET JAYA NO.18 BATU AMPAR 021-8090712|- 021-80881275 N Y RB,PHAR 021-87781605-06021-87781606|021- 501 0990 RS. JANTUNG BINA WALUYA CARDIAC CENTER JL. TB SIMATUPANG NO.71 021-8403869 Y Y ALL COVERAGE 87781606 502 1110 RSIA. RESTI MULYA JL. PAHLAWAN KOMARUDIN RAYA NO. 5 PENGGILINGAN CAKUNG 021-4803936-4802192-4803707| 021-48701488 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 503 1096 KLINIK YADIKA CIBUBUR JL. LAPANGAN TEMBAK NO.9 PEKAYON-CIBUBUR 021-8711515-|- 021-8711515 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 504 1258 KLINIK SUCI HUSADA JL. SUCI NO.21 RT.08/06 SUSUKAN - CIRACAS 021- 87798796| 021- 87798796 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 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 Y RB,PHAR 506 1262 RS. RAWAMANGUN JL. BALAI PUSTAKA RAYA, NO.29-31 021-4893531| 021-4710918 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 507 1538 KLINIK MITRASANA (DANKOS FARMA) JL. RAWA GATEL, BLOK IIIS, KAV.37-38, KAW.INDUSTRI PULO GADUNG 4600158/4600157| - N Y 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 021-8615754 / 021-8610756|021- 510 0888 RS. YADIKA PONDOK BAMBU JL. PAHLAWAN REVOLUSI NO.47 PONDOK BAMBU - JAKARTA TIMUR 021-8613332 Y Y ALL COVERAGE 8610756 511 0289 RS. OMNI MEDICAL CENTER JL. PULO MAS BARAT VI, NO.20 021- 2977 9999| 021-4718081,4708180 Y Y ALL COVERAGE

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed RS. PREMIER JATINEGARA ( RS MITRA 512 0012 JL. RAYA JATINEGARA TIMUR, NO.85-87 021-2800666/2800888|021-2800777 021-2800755 Y Y ALL COVERAGE INTERNASIONAL) 021- 513 0122 RS. MEDIROS JL. PERINTIS KEMERDEKAAN, KAV.149 021-4891937 Y Y ALL COVERAGE 4750042/4897415/4893036/4895817/472 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 514 0024 KLINIK PRIMA HUSADA CIBUBUR JL. LAPANGAN TEMBAK NO.2A CIBUBUR 021-87707503|021-9111938 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 515 0258 KLINIK DEVITA JL. JATINEGARA TIMUR NO.57 JATINEGARA 0218501134/0218516274|021-819 6041 021-85906901/8516274 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 516 0292 KLINIK PONDOK GEDE AGUNG JL. RAYA HANKAM, NO.58C-D, PONDOK GEDE 021-8464030| 021-8463803 N Y 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 (021) 8000693-95(021) 8000695|(021) 518 0806 RS. HAJI JAKARTA JL. RAYA PONDOK GEDE 021-80876175/8000152 Y Y ALL COVERAGE 8000695 519 0805 RSU. UKI JL. MAYJEN SOETOYO, CAWANG 021-8092317,8010526,8092831,8010523| 021-8092445/8005595 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 520 0807 KLINIK MHT TEGALAN JL. TEGALAN NO. 30 021-8581344| 021-8581344 N Y RB,PHAR 521 0779 RS. AU DR.ESNAWAN ANTARIKSA JL. MERPATI NO.2 LANUD (021) 8007027| (021) 8098 665 Y Y ALL COVERAGE RB & KLINIK 24 JAM MHT PONDOK GEDE D/H 021-8093602/80887175/74|021- 522 0382 JL. RAYA PONDOK GEDE, NO. 23-25, KRAMAT JATI 021-80887174 Y Y ALL COVERAGE RS PONDOK G 80887175 523 0826 RB & KLINIK SEJAHTERA CIRACAS JL. RAYA CIRACAS NO.7 021- 87717635/87712710/87712711-|- 021-87720232 Y Y ALL COVERAGE 021- 86603270/8661669/86603270|021- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 524 1012 KLINIK IBIN SINA JL.PENDIDIKAN RAYA NO.33 DUREN SAWIT 021-86601611 N Y 86603270 RB,PHAR RS. BHAYANGKARA TK.1 R.SAID SUKANTO 525 0944 JL. RAYA BOGOR KRAMAT JATI RS POLRI 021-8093288|- 021-8095310 Y Y ALL COVERAGE (POLRI) 021-86906363/021-5844330|021- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 526 0948 KLINIK SAPTA MITRA JALAN TAMAN MALAKA UTARA BLOK A12, MALAKAJAYA 021-86906363 N Y 5844330 RB,PHAR 021-4603916/4601371/021- 527 0099 RS. HARAPAN JAYAKARTA JL. BEKASI TIMUR RAYA, NO.6 KM.18, PULO GADUNG 021-4608863 Y Y ALL COVERAGE 46822879|021-46822879 528 0386 RS. HERMINA JATINEGARA JL. RAYA JATINEGARA BARAT, NO.126 021-8513838 / 8191223|021-8504371 021-8190111/8196157 Y Y ALL COVERAGE 021-4707433-37021-4707437|021- 529 1001 RS. DHARMA NUGRAHA JL. BALAI PUSTAKA BARU NO.19 RAWAMANGUN 021-4707429/8 Y Y ALL COVERAGE 4707437 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 530 1192 KLINIK & APOTEK PUTEWA JL. NUSA INDAH RAYA BLOK 40 NO.17H 021-8622207/70302043| 021-8622207 N Y 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 021-64715200/021-687813-14/6|021- 533 0587 RS. SATYA NEGARA JL. AGUNG UTARA RAYA, BLOK A, NO.1 021-6877813 Y Y ALL COVERAGE 687813-14/6 JL. PANTAI INDAH SELATAN 1, KOMP.ELANG LAUT BOULEVARD KAV.1 NO.1, 534 2458 RSIA. GRAND FAMILY 021-29673737/29678062/296333777| 021-29673747 Y Y ALL COVERAGE PENJARINGAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 535 6384 AUDY DENTAL PANTAI INDAH KAPUK JL. PANTAI INDAH SELATAN 1, RUKO ELANG LAUT BLOK NO.20 (021) 29219170 / 081291303052| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 536 1644 KLINIK SYIFA MEDICAL CENTRE JL. LONTAR LUAR NO.7 RT 004/04 TUGU UTARA KOJA KEC. KOJA 021-43935260| 021-43935375 N Y RB,PHAR 537 0170 RS. PLUIT JL. RAYA PLUIT SELATAN, NO. 2 021-6685006; 021-668507|021-668507 021-6684878 Y Y ALL COVERAGE JL. TANAH PASIR RUSUN PENJARINGAN BLOK MAWAR I A GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 538 3998 KLINIK PESONA TANAH PASIR 021-66675691/085101280470| - N Y KEL.PENJARINGAN,KEC.PENJARINGAN, JAKARTA UTARA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 539 2143 KLINIK PERTAMEDIKA DELI JL. DELI NO. 22 JAKARTA UTARA - 1-628 021-43923390 / 3389| 021-4353461 N Y RB,PHAR KLINIK MATA NUSANTARA (PANTAI INDAH RS. PANTAI INDAH KAPUK LT.8, JL. PANTAI INDAH UTARA NO. 3, KEL. 540 4377 (021) 5595 8236| (021) 5595 8393 N Y GP,OP KAPUK) KAPUK MUARA, PENJARINGAN, JAKARTA UTARA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 541 6383 AUDY DENTAL KELAPA GADING RUKO MAL OF INDONESIA BLOK K NO.3 KELAPA GADING (021) 45869153 / 082298757541| - N Y RB,PHAR RUKO CORDOBA BLOK G NO. 16 JL. MARINA RAYA INDAH GOLF NO.2 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 542 6390 J & J DENTAL CARE PENJARINGAN -| - N Y KEL.KAMAL MUARA KEC. PENJARINGAN JAKARTA UTARA RB,PHAR 021-4400781,4400778021-4400778|021- 543 0882 RS. ISLAM JAKARTA UTARA ( SUKAPURA ) JL. TIPAR CAKUNG NO.5 JAKARTA UTARA 021-44832228,4400782 Y Y ALL COVERAGE 4400778 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 544 4733 CLINIC PROTERA KIRANA BOUTIQUE OFFICE F2 NO. 1-2, KELAPA GADING, JAKARTA 14240 (021) 29365237| (021) 2936 5242 N Y RB,PHAR JL. TELUK GONG RAYA NO 12 RT.007/007 KEC. PENJARINGAN 545 4079 RS. DUTA INDAH (021) 6667 6188| (021) 6667 6190 Y Y ALL COVERAGE KEL.PENJAGALAN JAKARTA UTARA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 546 4513 PRODIA PANTAI INDAH KAPUK RUKAN GOLD COAST B3-B3 021-29032788-99| - N Y RB,PHAR JL. DANAU SUNTER UTARA BLOK C1 NO. 14, SUNTER AGUNG - JAKARTA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 547 3732 KLINIK PRODIA SUNTER -| - N Y UTARA 14350 RB,PHAR -KOMP. RUKO SENTRA BISNIS PLUIT, JL. PLUIT SAKTI RAYA NO. 28 A GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 548 3733 PRODIA PLUIT (021) 66603561, 66600571| - N Y BLOK A-6, JAKARTA UTARA 14440 RB,PHAR JL. BOULEVARD RAYA BLOK H 4 NO. 15, KELAPA GADING PERMAI, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 549 3734 PRODIA KELAPA GADING (021) 4522148| - N Y JAKARTA UTARA 14240 RB,PHAR 021-4521001/4520201021-4520201|021- 550 0748 RS. GADING PLUIT JL. BOULEVARD TIMUR RAYA, KELAPA GADING. JAKARTA UTARA 021-4520390 Y Y ALL COVERAGE 4520201 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 551 1746 LAB. KLINIK BIOTEST PLUIT JL. PLUIT SAKTI RAYA NO 25 JAKARTA UTARA 021-6622611| 021-6628166 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 552 1813 FRIENDLY DENTAL CARE JL. DANAU SUNTER UTARA BLOK C1 / 4 B JAKARTA UTARA 021-65836485| 021-65836484 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 553 1946 APOTEK KIMIA FARMA 46 JL. RAWA BADAK NO. 3, KOJA, JAKARTA UTARA 021-4393397| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 554 2144 KLINIK PERTAMEDIKA JL. YOS SUDARS. O NO. 34 JAKARTA UTARA - 1-628 021-43928260| 021-43908706 N Y RB,PHAR JL. MANGGAR NO.141 KEL.LAGOA, KEC.KOJA TANJUNG PRIOK JAKARTA GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 555 2412 KLINIK BERSALIN LESTARI 021 43922950| - N Y UTARA RB,PHAR JL. BOULEVARD TIMUR RAYA BLOK NB I NO 36 KELURAHAN PEGANGSAAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 556 2506 MITRASANA KELAPA GADING 021-36464908/4585455| - N Y DUA, KELAPA GADING JAKARTA UTARA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 557 1263 KLINIK SEMPER SISMA MEDIKA JL. KESEMEK, NO.3-5, SEMPER BARAT, CILINCING 021- 4400902/4403101| 021-4403101 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 560 1677 KLINIK SOLA GRACIA MEDICAL CENTER JL. SUNTER AGUNG UTARA BLOK A 17 D NO 1 021-6459530/6452041| 021-6459530; 6451274 N Y 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 021-4532493/021-4532494021- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 565 0910 KLINIK GADING UTAMA JL. KELAPA GADING BOULEVARD CN 2/25 021-4521933 N Y 4532494|021-4532494 RB,PHAR JL. PLUIT MAS I BLOK A NO.2A-5A, KOMPLEK PERUMAHAN PLUIT MAS, 021-6695066/6694990021-6694990|021- 566 0876 RSIA. FAMILY 021-6615563/66607254 Y Y ALL COVERAGE JAKARTA UTARA 6694990 GORONTALO

GORONTALO JL. , GORONTALO (EKS JL. DI PANJAITAN NO. 27, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 567 3731 PRODIA GORONTALO (0435) 826246| - N Y GORONTALO 96115) 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 0435-829255/ UGD 569 1513 RSU. BUNDA GORONTALO JL. HB.JASSIN, NO.269, KOTA GORONTALO 0435-827573 Y N H&S,MAT 830600/827573/829290|

Page 8 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

JAMBI

JAMBI SILOAM HOSPITALS JAMBI (D/H RS. ASIA 570 0894 JL. SOEKARNO - HATTA, PAALMERAH JAMBI 0741-5919000-|- 0741-573271/573238 Y Y ALL COVERAGE MEDIKA) 571 0550 RS. ST.THERESIA JL. , 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 08877800501/082146383275/074170785 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 573 2184 APOTEK KIMIA FARMA 208 JL. SOEMANTRI BROJONEGORO NO. 1 - N Y 71| RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 574 3570 PRODIA JAMBI JL. URIP SUMOHARDJO 2-3, TELANAI PURA, JAMBI 0741) 64688,| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 576 2644 KLINIK & APOTEK KF 299 JL. R.MATTAHER NO.40, RAWASARI, JAMBI 0741 25635| - N Y RB,PHAR 577 2372 RS. KAMBANG JAMBI JL. KOL. 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 JL. LEBAI HASAN RT. 06 RW. 02 KEL. SUNGAI PINANG, KEC. BUNGO DANI, (0747) 7331122/ 7331123, Hp. 0821 8461 579 5615 RSIA. PERMATA HATI MUARA BUNGO (0747) 7331123 Y Y ALL COVERAGE KAB. BUNGO 2206| JAWA BARAT

BANDUNG

580 1087 RS. BUNGSU JL. VETERAN, NO.6 022-4231550-|- 022-4231582 Y Y ALL COVERAGE 022-6031087, 6011913, 581 1088 RS. RAJAWALI JL. RAJAWALI NO.38 022-6032077 Y Y ALL COVERAGE 6079143,6051087-|- 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 584 1211 KLINIK ASRI HUSADA II JL. TITIRAN NO.16 022-2507293| 022-2507293 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 585 4123 LAB. PRODIA MTC METRO INDAH MALL BLOK B NO.5, JL. SOEKARNO HATTA, BANDUNG 022-7536256| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 586 4124 LAB. PRODIA PASIRKALIKI JL. PASIRKALIKI NO. 225, BANDUNG 022-2034685| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 587 3001 LAB. KLINIK BIOTEST NARIPAN JL. NARIPAN NO. 41 BANDUNG (022) 4205544| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 590 2625 KLINIK & APOTEK KF 12 JL. IR H JUANDA NO1 BANDUNG 022 4205421| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 591 2626 KLINIK & APOTEK KF 14 JL. CIAMPELAS 7, BANDUNG 022-4201596| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 592 2622 KLINIK UTAMA AL-ISLAM JL. AWIBITUNG NO.29 CICADAS BANDUNG 40121 (022) 7208284| (022) 7276149 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 595 2730 KLINIK & APOTIK K-24 JL. LASWI NO.1A,BANDUNG (022) 7821700/7215992| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 596 2704 KLINIK & APOTEK KF 43 JL. BUAH BATU, BANDUNG 022 7305019| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 597 2705 KLINIK & APOTEK KF 320 JL. CINUNUK NO.192, BANDUNG 022 7801875| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 598 2719 KLINIK JAYA SENTOSA JL. SUNDA NO.75, BANDUNG 022 426 4258| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 599 2720 KLINIK JAYA ABADI ( GROUP JAYA SENTOSA) JL. BUAHBATU NO.245 , BANDUNG (022) 7317779| - N Y RB,PHAR 600 0303 RS. ADVENT BANDUNG JL. CIHAMPELAS, NO.161 022 -2034386-9/2034388| 022-2043167/2041109 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 601 1900 TELEMEDIKA HEALTH CENTER (THC) SENTOT JL. SENTOT ALIBASYAH NO 4 BANDUNG 022-61115555| . N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 602 1568 KLINIK UTAMA MONALISA JL. MOCH. RAMDHAN NO.32 022-5211311| 022-5200162 N Y RB,PHAR 022-7208172,022-7217097, 022- 603 1170 RS. SANTO YUSUP JL. CIKUTRA 7 BANDUNG 022-7202419 Y Y ALL COVERAGE 7217103, 022-7231721| GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 604 2163 LAB. PRODIA BANDUNG JL. WASTUKENCANA NO.38 BANDUNG 022-4222541| - N Y RB,PHAR JL. TUBAGUS ISMAIL NO.79 RT/RW 004/012 KEL.SEKELOA KEC. COBLONG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 605 2167 APOTEK FARMARIN BANDUNG 2 TUBIS 022-2500387| 022-2517116 N Y BANDUNG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 606 2213 TELEMEDIKA FARMA 2 BB JL. TERUSAN BUAH BATU NO 33 022-70348587| - N Y RB,PHAR JL.RAYA CIMAREME NO.170-173 NGAMPRAH, PADALARANG, BANDUNG 607 1687 RS. IMC BANDUNG 022-6620923/6620965| 022 - 6620964 Y Y ALL COVERAGE BARAT 022- 608 0886 RSUD. AL IHSAN JL. KIASTRAMANGALA, BALEENDAH, 022-5941709 Y Y ALL COVERAGE 5940872/5941719/5941729/5940770/877 609 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 611 0958 KLINIK AN-NUR JL. DR. SETIA BUDI NO.63 022-2031922; 022 2042213|- 022-2031922/2042213 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 612 0959 KLINIK ASRI HUSADA I JL. BEKAMIN NO.18 022-7230425-87245792|- 022-2507293 N Y RB,PHAR 022- 613 0145 RS. MUHAMMADIYAH BANDUNG JL. KH. NO.53 022-7306458 Y Y ALL COVERAGE 7301062,7312167,7323549,7306935,7323 022-2552041/82558000/022-2552083/95; 614 0761 RS. SANTO BORROMEUS BANDUNG JL. IR.H.JUANDA NO.100 LEBAK GEDE COBLONG 022-2504235 Y Y ALL COVERAGE 022-2552003.|022-2552003 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 JL. PROF. DRG. SURYA SOEMANTRI NO. 65, RT. 01, RW. 04, KEL. 617 4986 RSGM. MARANATHA (022) 2005936| (022) 2019571 N Y ALL COVERAGE SUKAWARNA, KEC. SUKAJADI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 618 3678 PRODIA KOPO JL. KOPO PERMAI I BLOK 55 A / 6, BANDUNG 40227 (022) 5404291| - N Y 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 022-5201051/5201672/5201656|022- 621 0144 RS. IMMANUEL BANDUNG JL. KOPPO, NO.161 022-5224219 Y Y ALL COVERAGE 5224216 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 622 1265 APOTEK & KLINIK KIMIA FARMA SULAJANA 4 JL. SULAJANA NO.4 022-85880430/91512935| 022-4261088 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 623 3588 KIMIA FARMA SINDANGLAYA JL. AH.NASUTION NO.126 B BANDUNG 022-7278664| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 624 3560 LAB. PRODIA BUAH BATU JL. BUAH BATU NO. 160, BANDUNG 40265 (022) 7310128| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 625 4116 LAB. PRODIA KURDI JL. MOH TOHA NO. 126 BANDUNG (022) 5206492| - N Y RB,PHAR JL. CIPTO NO. 1 RT 05/02, KEL. PASIRKALI KEC. CICENDO, KOTA 626 2950 RS. KB. MELINDA II 022-4267888/4233777| 022-4247888 Y Y ALL COVERAGE BANDUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 627 5119 KLINIK BRAWIJAYA BANDUNG JL. KH. ACHMAD DAHLAN NO. 40, BUAH BATU, BANDUNG 022- 7308104| (022) 7311484 N Y RB,PHAR 628 1125 RS. CAHYA KAWALUYAN JL. PARAHYANGAN KM.3 KAV.HOS PADALARANG 022-6803700| 022-6803711/6803730 Y Y ALL COVERAGE 022-7562046 / 022-7563231|022- 629 0880 RS. AL ISLAM BANDUNG JL. SOEKARNO-HATTA NO.644 022-7563233/7500109 Y Y ALL COVERAGE 7563231 JL. PLUTO RAYA BLOK C RT. 01 RW. 02, KEL. MARGASARI KEC. BUAHBATU, 630 4967 RSKIA. HARAPAN BUNDA BANDUNG (022) 7506490| (022) 7514712 Y Y ALL COVERAGE BANDUNG 40286 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 631 6374 KLINIK JASMINE MQ MEDIKA JL. DAYANG SUMBI NO.10 RT.03/03 LEBAK SILIWANGI, COBLONG 022-20454500 / 20454502| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 632 3589 KIMIA FARMA 319 METRO JL. VENUS RAYA NO 27 0227564623| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 633 3591 APOTEK KIMIA FARMA 381 KOPO JL. KOPO CIRANGRANG NO.638 BANDUNG 022-5436596 / 085721647451| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 634 3592 KIMIA FARMA SETIABUDI JL. DR.SETIABUDHI NO 36, BANDUNG 022-2038048 / 0821200770017| - N Y RB,PHAR 635 1829 RSIA. LIMIJATI JL. LAKS L RE MARTADINATA 33-39 022-4207770/022-84281333/84469472| 0224-4260956 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 636 4517 PRODIA MAJALAYA JL. BABAKAN NO.60 MAJALAYA 022-5952724| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 637 4518 PRODIA BANJARAN JL. PAJAGALAN NO. 10 BANJARAN 022-5946190| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 638 2936 LAB. PRODIA BUMI MAS KENCANA RUKO BUMI MAS KENCANA, JL. AH. NASUTION 928 B CIKADUT BANDUNG 022-7236559| - N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

BANJAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 640 4122 LAB. PRODIA BANJAR JL. STADION PATROMAN KAV III NO. 3 0265-2732534| - N Y RB,PHAR BEKASI JL. TAMAN HARAPAN BARU BLOK E7 NO 9, PEJUANG, MEDAN SATRIA, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 641 2508 MITRASANA TAMAN HARAPAN BARU 88870793 / 08891259038| - N Y BEKASI BARAT RB,PHAR KLINIK 24 JAM & RB. PERMATA BUNDA GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 642 2461 JL. RAYA WANAJAYA - CIBITUNG, BEKASI 021 - 88322064, 88323062| - Y Y CIBITUNG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 643 6386 AUDY DENTAL BEKASI RUKO GRAND GALAXY CITY BLOK RGG NO.26 (021) 82733123 / 081212026161| - N Y RB,PHAR JL. RAYA CIKARANG SUKATANI NO. 3 DESA KARANG SENTOSA KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 644 6069 KLINIK CIPTO 2 (021) 89161455| (021) 89161455 N Y KARANG BAHAGIA KAB. BEKASI RB,PHAR JL. ALTERNATIF CIBUBUR -CILUENGSI RT.001/011, KEL. JATIKARYA KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 645 5614 KLINIK MATA UTAMA JEC CIBUBUR (021) 29221000| - N Y JATISAMPURNA, BEKASI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 646 2821 LAB. PRODIA BEKASI JL. KH NOER ALI NO.90 RT.01 RW.25 KAYURINGIN JAYA, BEKASI SELATAN. (021) 8840480, 8844911| - N Y RB,PHAR "Jl.Perum Mega regency Blok A09 Desa Sukasari Kec. Serang baru kab. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 647 2513 MITRASANA MEGA REGENCY 2 0815101487758| - N Y Bekasi 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 JL. RAYA TAMAN NAROGONG INDAH BLOK A10 NO.3, PENGASINAN, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 649 5795 KLINIK PRATAMA IMANI MEDIKA (021) 82731078| - N Y RAWALUMBU RB,PHAR 650 6010 RS. TARUMAJAYA JL. RAYA TARUMAJAYA NO.1B KP.BALI, PANTAI MAKMUR, TARUMAJAYA 021-88992337 / 88992338| Y Y ALL COVERAGE JL. NO.81-83, KAWASAN PENDIDIKAN JABABEKA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 651 6068 PRESIDENT MEDICAL CENTER 021-29469400 / 29082423| - N Y RUKO INFO PLAZA CIKARANG BARU RB,PHAR VILA MUTIARA CIKARANG 2 BLOK E3 NO.16-20 SUKASEJATI, CIKARANG 652 2036 RSU. DR. IQBALI TAUFAN 021-8971769/89902361| 021-89902361 Y Y ALL COVERAGE SELATAN - BEKASI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 653 0151 KLINIK MULYA MEDIKA (APOTIK MURNI) JL. RAYA JATI MULYA, NO.1, BEKASI TIMUR 021-8203272| 021-8203272 N Y RB,PHAR JL. TAMAN HARAPAN BARU RAYA, BLOK R-I NO.20, PEJUANG - MEDAN 654 1296 RSB. TAMAN HARAPAN BARU 021-88871202| 021- 88871203 Y Y ALL COVERAGE SATRIA 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 662 1951 KLINIK & APOTEK KF 387 JL. JATIWARINGIN NO 5 PONDOK GEDE BEKASI 021-8461980| - N Y RB,PHAR 021-82430101/82400186/8229767021- 663 1053 RS. ST. ELISABETH - BEKASI JL. RAYA NAROGONG NO.202 KEMANG PRATAMA 021-82432083 Y Y ALL COVERAGE 82432082|021-82432082 JL. RAYA BURANGKENG PERUM MUSTIKA GRANDE BLOK J NO. 5 DESA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 664 5422 KLINIK MUSTIKA HUSADA (021) 88326109/087880880370| - N Y BURANGKENG KEC. SETU, BEKASI RB,PHAR JL. RAYA PONDOK TIMUR KM. 1, NO 27 JATIMULYA TAMBUN SELATAN- 665 1304 RS. PUSPA HUSADA 021-82618978/82618979| 021-82618977 Y Y ALL COVERAGE BEKASI JL. KH. MUHTAR THABRANI NO. 3-5 KEL. PERWIRA, KEC. BEKASI UTARA, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 666 4726 KLINIK CAHAYA AMALIA (021) 88879888| (021) 88881747 N Y BEKASI RB,PHAR JL. CUT MUTIA BLOK D NO. 9 RT. 008/ 008 KEL. MARGAHAYU, KEC. BEKASI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 667 5220 VIVA MEDIKA BEKASI TIMUR (021) 8834 8228| - N Y TIMUR, BEKASI RB,PHAR JL. CHAIRIL ANWAR BLU PLAZA NO. 27 RT.004/009 KEL. MARGAHAYU KEC. 668 5221 RS SILOAM BEKASI TIMUR d/h BLU PLAZA (021) 806 11 900| (021) 806 11 911 Y Y ALL COVERAGE BEKASI TIMUR, BEKASI RUKO TAMBUN CITY BLOK RB NO. 16, JL. SULTAN HASANUDDIN KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 669 5222 VIVA MEDIKA TAMBUN 088888553853| - N Y TAMBUN SELATAN RB,PHAR RUKO CIKARANG CENTRAL CITY BLOK F NO. 23, JL. CIKARANG CIBARUSAH GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 670 5223 VIVA MEDIKA CIKARANG (021) 2961 9212| - N Y DESA CIANTRA KEC. CIKARANG SELATAN, BEKASI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 671 4385 KLINIK & APOTEK KF 340 JL.KEDASIH RAYA NO.112 CIKARANG -| - N Y RB,PHAR RUKO SENTRA NIAGA, BOULEVARD HIJAU BLOK C5/41 HARAPAN INDAH, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 672 3702 PRODIA HARAPAN INDAH (021) 29465476| - N Y BEKASI RB,PHAR 673 0010 RS. MITRA KELUARGA BEKASI BARAT JL. JEND. A.YANI, BEKASI BARAT 021-8853333| 021-8842550/8855000 Y Y ALL COVERAGE JL. RAYA LASKAR NO.59 RT.004/02, KEL.PEKAYON JAYA, KEC.BEKASI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 674 2544 MITRASANA TAMAN CENTURY 085100487742| - N Y SELATAN RB,PHAR 675 0766 RS. ANANDA BEKASI JL. SULTAN AGUNG NO.173, MEDAN SATRIA 021-8854338| 021- 88950141 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 676 0843 KLINIK DHARMA BHAKTI JL. RAYA BOSIH BLOK A4 NO.23 PONDOK TANAH MAS, CIBITUNG - BEKASI 021-8831441-|- 021-8831441/8830246 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 677 4515 PRODIA SUMMARECON BEKASI JL. BULEVAR SELATAN SUMMARECON BEKASI RUKO SINPASA BLOK SA 021-8840480| - N Y RB,PHAR 678 1350 RS. MITRA KELUARGA CIBUBUR JL. ALTERNATIF TRANSYOGI, CIBUBUR 021-84311771/84311777| 021-84311661 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 679 3382 KHARISMA MEDICAL CENTER JL. CAMAN RAYA NO.54 BEKASI 021-84991671| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 680 1204 KLINIK SEHAT SEJAHTERA II PERUM REGENSI - BEKASI TIMUR 021-88367194| 88349427 N Y RB,PHAR JL. RAYA CIBARUSAH NO. 33KEL. SUKARESMI, KEC. CIKARANG SELATAN, 681 4814 KLINIK MULTAZAM (021) 9874929| - N Y ALL COVERAGE BEKASI GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 682 1558 KLINIK ASYIFA HUSADA PERUM. VILLA MUTIARA JAYA BLOK N. 78 /11-12, WANAJAYA, CIBITUNG 021-88338235| 021-88338235 N Y RB,PHAR JL. MANGUN JAYA RAYA KP.RUKEM RT.003/013, DESA MANGUN JAYA, 021-88338346/88327281/021- 683 0735 RS. KARTIKA HUSADA TAMBUN 021-88322529 Y Y ALL COVERAGE TAMBUN - BEKASI 9172736|021-9172736 684 4693 RS. CIKUNIR JL. RAYA CIKUNIR GG. HJ NAPSIAH RT.06/03 , JAKAMULYA (021) 82437322| (021) 82437323 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 685 3956 APOTEK KIMIA FARMA CAHAYA AMALIA JL. KH.MUCHTAR TABRANI NO.3-4, KEL.PERWIRA BEKASI UTARA 02188879888| - N Y RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 686 4484 KLINIK & RB KARUNIA MEDIKA CENTER JL. GATOT SUBROTO NO. 37 RT.003/002 KEL. CIKARANG - BEKASI 021-89104266| - N Y RB,PHAR JL. RAYA KARAWANG BEKASI KM 30 DS. BOJONGSARI KEDUNGWARINGIN 687 4811 RSU. AS-SHOFWAN (021) 89141890| (021) 89141754 Y Y ALL COVERAGE KAB. BEKASI 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 689 2511 MITRASANA DUKUH ZAMRUD JL. ZAMRUD UTARA RUKO BLOK S.1 NO. 18 KOTA LEGENDA,BEKASI TIMUR 08891258897/ 82602911| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 692 2433 KLINIK TAMAN FIRDAUS MEDIKA PERUM TAMAN FIRDAUS RESIDENCE BLOK A 06 NO.17 CIBARUSA BEKASI 021 - 89950047| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 693 2573 MITRASANA BUMYAGARA TAMAN BUMYAGARA A.04 KEL MUSTIKA JAYA 085100464921| N Y RB,PHAR VILA MUTIARA GADING 2 KOMPLEK RUKO ROXY BLOK DD.10 NO.1 KARANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 694 2611 KLINIK AMELIA 021-88376985| - N Y SATRIA BEKASI RB,PHAR JL. KH MUCHTAR TABRANI RT 003 RW 03 KEL. PERWIRA KEC. BEKASI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 695 2560 MITRASANA MOCHTAR TABRANI 36822504/ 08891259008| - N Y UTARA KOTA BEKASI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 696 2585 MITRASANA WIBAWA MUKTI JL. WIBAWA MUKTI RT.01/11 KP.PEDURENAN, JATIASIH 021-36487743| - N Y RB,PHAR "RUKO FITRA JAYA, JL. KALIABANG RT 01/06 NO. 7 KEL PERWIRA KEC GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 697 2515 MITRASANA KALIABANG 021-88974206| - N Y BEKASI UTARA RB,PHAR "KAMPUNG UJUNG HARAPAN RT 02/ RW 15 KEL. BAHAGIA KEC. BABELAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 698 2520 MITRASANA UJUNG HARAPAN 021-29258727/ 70874627| - N Y KAB. BEKASI RB,PHAR PONDOK TIMUR INDAH BLOK G NO 1 PONDOK TIMURKEL JATIMULYA KEC GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 699 2539 MITRASANA PONDOK TIMUR 085100822510| - N Y TAMBUN SELATAN KAB BEKASI RB,PHAR JL. PERUM TITIAN INDAH BLOK I NO 9 RT 07 RW 10 KEL. KALIBARU KEC GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 700 2545 MITRASANA TITIAN INDAH 021-94178815| - N Y MEDAN SATRIA KOTA BEKASI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 701 2613 KLINIK & APOTIK MAHADINA MEDIKA JL. KH. BOSIH NO.9 CIBITUNG -| - N Y RB,PHAR JL. KH. FUDHOLI (KEBON KPI) DESA KARANG ASIH, KEC. CIKARANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 702 3367 KLINIK CENTRAL MEDIKA2 021-89100879| 021-89100877 N Y UTARA KAB. BEKASI RB,PHAR JL. RAYA PILAR SUKATANI KP. SUKAMANTRI NO 62 RT 03/03 DS SUKARAYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 703 3447 KLINIK RAWAT INAP PEDULI SEHAT 021-8903208| 021-89100139 N Y KEC KARANG BAHAGIA 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 RUKO KALIMALANG SQUARE BLOK J NO. 17, JL. KALIMALANG RAYA - GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 705 2802 KLINIK PERTAMEDIKA BEKASI 021-88962946| - N Y BEKASI BARAT RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 706 2803 KLINIK PERTAMEDIKA JATIWARINGIN ASRI JL. SANGATTA NO. 1 JATIWARINGIN PONDOK GEDE 17411 021-84990644| 021-84970944 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 707 2689 KLINIK & APOTEK KF 367 JL. JATIMEKAR NO. 33 JATIASIH 021 8473403| N Y RB,PHAR JL. PERUM GRIYA BEKASI PERMAI BLOK H6 NO 17, TELAJUNG-CIKARANG 708 1971 RB. WIJAYANTI 021-29371856/97958619| 021-82602243 Y Y ALL COVERAGE BARAT RUKO SENTRA NIAGA KALIMALANG, JL. A.YANI BLOK A9 NO. 16, KEL. 709 4378 KLINIK MATA NUSANTARA (BEKASI) (021) 2925 7761| (021) 2925 7762 N Y GP,OP MARGA JAYA, KEC. BEKASI SELATAN RS KARYA MEDIKA BANTAR GEBANG(d/h KARYA 710 0147 JL. NAROGONG RAYA, KM.11, BANTAR GEBANG 021-8254629/8254630|021-8254630 021-8254629 Y Y ALL COVERAGE MEDIKA IV) JL. KH. NOER ALI NO. 1D RT. 001 RW.016, JAKA SAMPURNA, BEKASI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 711 4743 KLINIK TRAYA (021) 21286002| - N Y BARAT BEKASI 17137 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 712 1293 KLINIK YAKESTI BEKASI JL. RAYA NAROGONG KM.7 NO.45 BOJONG MENTENG -021 8253516| - N Y 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 RS. AWAL BROS BEKASI (D/H RS. GLOBAL 714 1486 JL. KH.NOER ALI KAV.17-18 KALIMALANG 021-8868888/88855333| 02188855222/88855210 Y Y ALL COVERAGE AWAL BROS ) 715 1816 RS. HARAPAN MULIA JL. RAYA CIBARUSAH NO. 5 KB. KOPI, CIBARUSAH JAYA KAB. BEKASI 021-89952340| 021-89952460 Y Y ALL COVERAGE

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 716 1830 RB & KLINIK AMIRA CIKARANG JL. RAYA BY PASS LEMAH ABANG, CIKARANG TIMUR 021-8914 2719| 021-89142719 Y Y RB,PHAR JL. GURAME RAYA PERTOKOAN KAV.29 PERUMNAS KAV.29 PERUMNAS II GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 717 1937 APOTIK FARMARIN VII BEKASI 02188968419| - N Y KEL, KAYU RINGIN RAYA KEC BEKASI SELATAN. RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 718 1924 KLINIK MANDIRI PERUM VILLA MUTIARA CIKARANG BLOK R 26-27 CIKARANG SELATAN 021-897 4883| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 719 1530 KLINIK SIERRA MITRA JL. KH. M.TABRANI BLOK I NO. 1 A-1B, MARGAMULIA, BEKASI UTARA 021-70266392/8868129| 021-8868129 N Y RB,PHAR 720 1541 RS. PERMATA BEKASI JL. LEGENDA RAYA, NO. 9, MUSTIKA JAYA 021-8251919/8254748| 021-82609705 Y Y ALL COVERAGE GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 721 1559 RB & KLINIK TIARA BUNDA JL. RAYA PERJUANGAN NO. 1, PERTIGAAN TELUK PUCUNG 021-89131010| 021-89131010 Y Y RB,PHAR 722 1122 RS. JATI SAMPURNA JL. STUDIO ANTV KRANGGAN 021-8451457/8455874| 021- 8455712/8459464 Y Y ALL COVERAGE RS TAMAN HARAPAN BARU (d/h praktek 723 1576 JL KALIABANG TENGAH RT 04/23 KEL. PEJUANG KEC. MEDAN SATRIA 021-88981055| 021-88981055 Y Y ALL COVERAGE bersama dokter) 021-8215101/8215102021-8215102|021- 724 0063 RS. MULTAZAM MEDIKA JL. PERUMAHAN JATIMULYA NO.1 TAMBUN SELATAN 021-82416678 Y Y ALL COVERAGE 8215102 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 021-8900190-1& 8903003-4/ 8900190-1 726 0016 RS. KARYA MEDIKA CIBITUNG JL. RAYA IMAM BONJOL, NO.9B, CIKARANG BARAT, CIBITUNG 021-89107753-4 Y Y ALL COVERAGE (ext:181)| 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 KOMPLEK PEMDA BLOK C KAV 60 B, JL WARUNG BUAH KOMSEN JATI ASIH GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 728 1595 KLINIK VNV MEDIESTETI 021-824 15167/ 82435767| 021-82435767 N Y BEKASI RB,PHAR JL. KH. NOER ALI NO. 10 KP. IRIAN RT. 03/04 TELUK PUCUNG, BEKASI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 729 2057 KLINIK BATARA SATU MEDIKA 021-89133229/085100589090| 021-82589090 N Y UTARA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 730 2091 KLINIK SITI ZAHROH PERUMAHAN GRAND RESIDENT RR 100 SETU - BEKASI 021-8261.8362| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 732 1640 RS. JATI RAHAYU JL. RAYA HANKAM NO 17 PONDOK MELATI BEKASI 021-8462566,8462565,84972578| 021-84992723 N Y RB,PHAR BEKASI SQUARE NO 65-66 JL. AHMAD YANI PEKAYON JAYA BEKASI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 733 1769 KLINIK SATELIT GSM BEKASI 021-82425408| - N Y SELATAN 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 736 0409 KLINIK DHARMA MEDIKA JL. PEMUDA, NO.33, KRANJI 021-8855173,8866711| 021-8866711 N Y RB,PHAR 737 0185 RS. BHAKTI KARTINI JL. KARTINI, NO.11 021-8801954/88348492| 021-8824228 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 738 0767 KLINIK MHT BEKASI JL. H.M JOYO MARTONO NO.31B BEKASI TIMUR 021-8814262| 021-8814262 N Y RB,PHAR 021-883 24366; 70934766/ 021- 739 0620 RS. KARYA MEDIKA II (D/H RSIA. ) JL. SULTAN HASANUDIN NO.63 TAMBUN 021-88327514 Y Y ALL COVERAGE 88361980|021-88361980 021-880 1775/ 880177/8819377021- 740 0410 RS. BELLA JL. IR. H. JUANDA, NO.141 BEKASI 02188342438/88352506 Y Y ALL COVERAGE 880177|021- 880177 021-8802641,8813787021-8813787|021- 741 0384 RS. MEKAR SARI JL. MEKAR SARI, NO.1 021-8810055/88350908 Y Y ALL COVERAGE 8813787 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 742 0250 KLINIK KARYA MEDIKA I JL. IR H JUANDA NO.38 C 021-8801293021-8800381|021-8800381 021-8816137 N Y RB,PHAR KLINIK FAJAR MEDIKA ( GROUP KARYA MEDIKA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 743 0188 RUKO KAWASAN INDUSTRI MM2100, CIBITUNG 021-8981162| 021-8981162 N Y ) RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 744 0715 KLINIK MUTIARA I (CITRA HUSADA I) PERUM METLAND JL. KALIMAYA 6 BLOK L2 / 1 BEKASI 021-29487893| 021-88337919 N Y RB,PHAR KLINIK KARYA MEDIKA III (APOTIK MEKAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 745 0294 JL. PERJUANGAN, NO.30C, TELUK BUYUNG 021-8851152| 021-8851152 N Y ASRI) RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 746 0819 RB & KLINIK PERMATA BUNDA SETU PERUM GRAHA MUSTIKA MEDIA, BLOK A5, NO.15, SETU 82611729 / 88328001| 82611729 Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 747 0873 APOTIK & KLINIK LEGENDA SEHAT JL. ZAMRUD UTARA BLOK U16 NO.100 KOTA LEGENDA 021-82600148| 021-82606179 N Y RB,PHAR 748 1013 RSIA SELASIH MEDIKA JL. RAYA BINTARA NO 5, BEKASI BARAT 021-8850155| 021-8844667 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 749 1038 KLINIK HARAPAN SEHAT III PERUMAHAN VILLA MUTIARA JAYA, BLOK MB 16/7, CIBITUNG 021- 68295994/88393875-|- - N Y 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 BP DR. SANDER B(D/H KLINIK HOSANA MEDICA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 751 0949 JL. TEUKU UMAR NO.19 CIBITUNG 021-8833 8414-|- 021-8833 8413 N Y CIBITUNG) RB,PHAR KLINIK HOSANA MEDICA MANGUN JAYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 752 0950 JL. MANGUN JAYA INDAH II BLOK G10 NO. 3 TAMBUN BEKASI 17510 (021) 8832-0349-|- (021) 8832-0349 N Y (HOSANA MEDIKA IV RB,PHAR JL. DESA JATIWANGI-CIKEDOKAN/SEBELAH SELATAN KAWASAN MM 2100 753 0622 RSU. MITRA MEDIKA 021-8998 3741/71691709/98213879| 021-89983575 Y Y ALL COVERAGE KP KAMURANG RT 1/1 CIKEDOKAN, CIKARANG BARAT GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 754 0588 KLINIK MELVIANA JL. SAPARUA RAYA NO.239 - 240 PERUMNAS III BEKASI 082213067595; 021 - 8807610| 021-88341291 N Y 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 021- 8811832, 8821004, 756 0324 RS. GRAHA JUANDA JL. IR. H. JUANDA, NO.326 021 - 88346880 Y Y ALL COVERAGE 8811832,88346880|021- 8811832 757 1140 RS. RAWA LUMBU JL. DASA DARMA, NO.20-23, RAWA LUMBU 021-82422511| 021-82432958 Y Y ALL COVERAGE JL. KASUARI IV NO. 1-2, SEKTOR MEKAR ALAM, PASIMAL - CIKARANG 758 0960 RSB. MEKAR MULIA 021-8936940/66/|- 021-89830523 Y Y ALL COVERAGE BARU 759 1334 RS. ANNA MEDIKA JL. RAYA PERJUANGAN NO 45, HARAPAN BARU, BEKASI UTARA 021 - 88882211| 021 - 88973042 Y Y ALL COVERAGE 021-8842336/8893486021-8893486|021- 760 0982 RS. BUDI LESTARI JL. KH.NOER ALIE, NO.2 DEPAN PERUMNAS II, KALIMALANG 021-8893487 Y Y ALL COVERAGE 8893486 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 763 1120 KLINIK PURI NUSAPHALA JL. CITRA INDAH A/14 PERUM PURI NUSAPALA JATI ASIH 021-82440368/7| 021-82440368 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 764 1207 KLINIK DIPONEGORO JL. DIPONEGORO NO.26 TAMBUN 021 - 8817062| 021-88346743 N Y RB,PHAR 765 1216 RS. JUWITA JL. M. HASIBUAN NO.78 - BEKASI 021 -8829590/1| 021-8829592 Y Y ALL COVERAGE 021- 88373158 / 021-88328001/ GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 766 1136 KLINIK PERMATA BUNDA BEKASI JL. BOSIH RAYA RUKO KARTIKA WANASARI BLOK.C1/4 CIBITUNG - N Y 88392537| RB,PHAR 767 1090 RS. PERMATA CIBUBUR JL. ALTERNATIF CIBUBUR - CILEUNGSI NO.6A 021-8458806|- 021-84594263 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 768 1259 KLINIK WIJAYA KESUMA JL. NAROGONG SAKTI RAYA BLOK A 20 NO.1 021 - 8210779| 021 - 8226455 N Y RB,PHAR 769 1417 RSIA. RINOVA INTAN JL. RAYA SEROJA NO.101 021-8849401| 021-8848739 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 770 1203 KLINIK SEHAT SEJAHTERA I JL. NUSANTARA RAYA NO.2 PERUMNAS III BEKASI TIMUR 021-88349427| 88349427 N Y 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 JL. RAYA CIKARET NO. 12 RT.03 RW.10 KAMPUNG POS PAKANSARI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 773 1913 KLINIK PURI MEDIKA 021-87903120| - N Y CIBINONG, BOGOR RB,PHAR 774 1353 RS. CITAMA JL. RAYA PABUARAN NO.52 BOJONGGEDE 021-87985555| 021-87986666 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 775 1533 KLINIK DR.BETTY JL. RAYA NAROGONG, PERUMAHAN PT.SEMEN CIBINONG, CILEUNGSI 021-82493032| - N Y 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 021-8758441; 87911000021- 8753422- 777 0755 RS. BINA HUSADA CIBINONG JL. MAYOR OKING NO.101, CIBINONG 021-8752463 Y Y ALL COVERAGE |021- 8753422- 0251 - 8611507/86177270251- 778 0720 RSIA. CITRA INSANI JL. RAYA PARUNG NO.242, LEBAKWANGI PEMAGARSARI, PARUNG 0251 - 8617493 Y Y ALL COVERAGE 611507|0251-611507 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 779 1952 KLINIK & APOTEK KF 50 JL. MERDEKA NO 24 BOGOR 0251-8384247 / 8321525| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 780 1734 TELKOMEDIKA HEALTH CENTER (THC)BOGOR JL. PENGADILAN NO. 14 BOGOR 0251 - 8380134| N Y 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 0251- 783 0992 RS. BOGOR MEDICAL CENTER JL. PAJAJARAN INDAH V/97 BOGOR 0251-8313987/8353419 Y Y ALL COVERAGE 8307900/8390435/8346002/83797430251- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 784 0706 POLIKLINIK CIBULUH JL. KEDUNG HALANG TALANG, NO.148 0251-8661947| - N Y RB,PHAR 0251- 8321196021-4506389|021- 785 0673 RSU. MELANIA JL. RAYA PAHLAWAN NO.91 BONDONGAN - BOGOR 0251-8331777 Y Y ALL COVERAGE 4506389 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 788 0932 KLINIK MHT CIPAYUNG JL. RAYA PUNCAK CIPAYUNG, KM 75 0251-8256172-|- 0251-8257648 N Y RB,PHAR 789 0290 RS. MARY CILEUNGSI HIJAU JL. RAYA NAROGONG, KM.21, CILEUNGSI 021-82492222| 021-82493902 Y Y ALL COVERAGE 021-8763055-56021-8765993|021- 790 1103 RS. TRIMITRA CIBINONG JL. RAYA CIBINONG KM.43 021-8758038 Y Y ALL COVERAGE 8765993 RB & KLINIK CITAMA KEDUNG WARINGIN GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 791 1419 JL. BOJONG GEDE-BOGOR 021-87983434| Y Y GAVERI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 792 1525 EMMA MEDICAL CENTER 2 JL. RAYA CICADAS, KM.9, NO.21, GUNUNG PUTRI 021-86860577/91304486| 021-86860578 N Y RB,PHAR

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 795 1251 KLINIK INSANI CIBINONG JL. MAYOR OKING JAYAATMAJA NO.58A, CIRIUNG, CIBINONG 021-8757567| 021-8757567 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 798 2824 LAB. PRODIA BOGOR JL. JEND. SUDIRMAN NO.38 B, BOGOR 16143 (0251) 8351612, 8351614| 0251-8351614 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 799 2624 IZI CLINIC JL. ACHMAD ADNAWIJAYA NO.115 (0251) 8359111| - N Y 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 021-87909999/87911212/(021) 802 1385 RS. SENTRA MEDIKA CIBINONG JL. MAYOR OKING JAYA ATMAJA NO.9 CIBINONG 021-87909377 Y Y ALL COVERAGE 80635969.| 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 805 1833 KLINIK PELITA SEHAT TAMAN KENARI RUKO PERUMAHAN TAMAN KENARI BLOK E3 NO 4, TANAH BARU BOGOR 0251-8664767| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 806 1831 KLINIK PELITA SEHAT CIBINONG CENTRAL RUKO CIBINONG BLOK B No 1-2 JL. MAYOR OKING No 63 021-87910241/08998513939| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 807 2718 KLINIK PELITA SEHAT CIOMAS JL. RAYA TAMAN PAGELARAN BLOK C1 NO.5, PADASUKA, CIOMAS, BOGOR (0251) 7522167| - N Y RB,PHAR JL.RAYA NARONGONG BEKASI KM. 19,5 RT. 003 RW. 002 DESA LIMUS, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 808 5813 KLINIK PRATAMA RAWAT INAP BUKAKA (021) 8231764| (021) 8231717 N Y NUNGGAL, KEC. CILEUNGSI, KAB. BOGOR RB,PHAR JL. RAYA KARET VILLA TELAGA CIBINONG NO.07-08, HARAPAN JAYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 809 2753 KLINIK ARABBANI (021) 87910118;| (021) 87910118 N Y CIBINONG, BOGOR RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 810 1235 KLINIK & APOTEK KF 7 BOGOR JL. IR. H JUANDA NO. 30 0251-8363473 / 8319030 (Lab)| N Y RB,PHAR 021-8235052 / 82491332021- 811 0389 RS. MH THAMRIN CILEUNGSI JL. RAYA NAROGONG, KM.16, LIMUS NUNGGAL, CILEUNGSI 021-82491331 Y Y ALL COVERAGE 82491332|021-82491332 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 812 4983 KLINIK GRACIA JL. RAYA NAROGONG KM. 17 (PANGKALAN 9) CILEUNGSI, (021) 82486305| (021) 82486305 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 815 2172 KLINIK BHAKTI RAHAYU LEUWILIANG JL. RAYA GALUGA NO. 120 CIBUNGBULANG, BOGOR 0251-8648201| - N Y RB,PHAR 816 0411 RS. AZRA JL. RAYA PAJAJARAN, NO.219 0251-8318456|- 0251-8331773/8324093 Y Y ALL COVERAGE JL. RAYA JONGGOL NO.1 A RT.008 RW.03, KEL.SUKAMANAH, JONGGOL, 817 2955 RS. PERMATA JONGGOL 021 - 89931222/3| 021- 8993 1836 Y Y ALL COVERAGE BOGOR 818 3420 RS. MULIA PAJAJARAN JL. RAYA PAJAJARAN NO. 98, BOGOR 0251-8379898 / 081288015174| 0251-8378800 Y Y ALL COVERAGE JL. KH ABDULLAH BIN NUH RT. 005/ RW. 01 KEL. SINDANG BARNAG, KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 819 2441 KLINIK NADYA MH THAMRIN (0251) 8624629| - N Y BOGOR BARAT 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 822 2772 KLINIK SHIFA MEDIKA JL. BRANTA MULIA RT.002/07 KARANG ASEM TIMUR, CITEUREUP - BOGOR (021) 8760357| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 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 Y RB,PHAR 824 2788 RSIA. ASSALAM JL. RAYA BOGOR KM 46, NANGGEWER MEKAR, CIBINONG (021) 8753724| - Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 825 2703 KIMIA FARMA 362 JL. MAYOR OKING 112 C, CIBINONG 021 87914400| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 826 2979 LAB. KLINIK KIMIA FARMA BOGOR JL. IR. H. JUANDA NO. 30, BOGOR 0251 - 8319030/8363473| - N Y RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 827 1297 RB & KLINIK INSANI JL. PAHLAWAN NO.73B DESA KARANG ASEM TIMUR, CITEUREUP 021- 87942723/70247742| 021-87942570 Y Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 830 1832 KLINIK PELITA SEHAT BANGBARUNG JL. ACHMAD SOBANA/ BANGBARUNG 77 BOGOR 0251-8362525 / 089637057022| - N Y RB,PHAR JL. KSR DADI KUSMAYADI RUKO LAMPU MERAH CIKARET NO. 70 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 831 1823 KLINIK SALSABILA MEDICAL CENTRE 021-87905768| - N Y CIBINONG-BOGOR RB,PHAR CIAMIS 0265-771650/7767450711-356173|0711- 832 1104 RS. PERMATA BUNDA CIAMIS JL. MR.IWA KUSUMASOMANTRI NO.1 0265-777658 Y Y ALL COVERAGE 356173 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 833 4125 LAB. PRODIA CIAMIS JL. JEND. SUDIRMAN NO. 99, CIAMIS 0265-2750977| - N Y RB,PHAR CIANJUR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 834 2123 KLINIK PADJADJARAN SUKANAGARA JL. RAYA SUKANEGARA KM.45 SUKANEGARA - CIANJUR 0263-340189/ 085794056664| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 835 2121 KLINIK ASSALAM CIKALONG JL. RAYA CIKALONG KULON NO. 61 A KAB. CIANJUR 0263-318222| - N Y RB,PHAR 836 4107 RS. DR.HAFIZ JL. PRAMUKA NO. 15 SUKAMULYA, KARANG TENGAH, CIANJUR 0263-2910000| (0263) 2910010 Y Y ALL COVERAGE

CIKAMPEK GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 837 1497 KLINIK SEHAT JL. PAWARENGAN NO. 37, DESA DAWUAN TIMUR 0264-8385103| 0264-8385103 N Y RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 838 2472 RB & KLINIK NAURAH MEDIKA JL. A. YANI NO.02 RT.03 RW. 06 DS. CIKAMPEK SELATAN, CIKAMPEK (0264) 8389999| - Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 839 0908 KLINIK KELUARGA GRAHA MEDIS JL. ACHMAD YANI NO. 51 0264-310101| 0264-310101 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 840 0093 KLINIK AQMA CIKAMPEK JL. STASIUN, NO.93 0264 - 310 524| 0264 - 319307 N Y RB,PHAR 0264-311531/316101/ 311514/ 841 0540 RS. SARASWATI JL. JEND. A.YANI, NO.92, DAWUAN, CIKAMPEK-KARAWANG 0264-311531 Y Y ALL COVERAGE 3115270264-316391|0264-316391 842 0375 RS. KARYA HUSADA JL. JEND. A.YANI, NO.98, CIKAMPEK-KARAWANG 0264-316188-89| 0264-312834/301626 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 843 1172 KLINIK PUTRA MEDIKA ( GROUP AQMA PUSAT ) JL. IR. H. JUANDA NO.14-19 SUKASEURI 0264-301652 / 8387129| 0264-8387129 N Y RB,PHAR 844 1239 RUMAH SAKIT IZZA JL. KP.CISELAN DS.CIKAMPEK UTARA.KARAWANG 0264-319307/8386830-32| 0264-8386829 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 845 1300 KLINIK ANDINA CIKAMPEK JL. IR.H.JUANDA NO.17 0264-303759| 0264-8387680 N Y RB,PHAR 846 2445 RS. TITIAN BUNDA JL. IR. H. JUANDA NO.123 CIKAMPEK (0264) 8385999/8386222| (0264) 8388936 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 847 1302 KLINIK PURI ASIH CIKAMPEK JL. STASIUN NO.2 CIKAMPEK KOTA 0264-303558| 0264-303558 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 848 1749 APOTEK NAGASARI JL. JEND A. YANI NO.177 CIKAMPEK 0264-316203| 0264-316203 N Y RB,PHAR CIKARANG JL. RAYA CIKARANG CIBARUSA NO 88 DS. SUKARESMI CIKARANG 849 1523 RSIA. NURUL ANNISA 021-897 4854/55| 021 - 8971122 Y Y ALL COVERAGE SELATAN, BEKASI 021-8904165/8901962/8904503021 - 850 0306 RS. ANNISA CIKARANG JL. RAYA CIKARANG BARU, NO.31, LEMAH ABANG, CIKARANG UTARA 021-8903350/89113827 Y Y ALL COVERAGE 8904503|021 - 8904503 021-8900530/1021-890 0531|021-890 851 0385 RS. BHAKTI HUSADA JL. RE. MARTADINATA 021-8900570 Y Y ALL COVERAGE 0531 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 852 2087 KLINIK JB MEDICAL CENTER SHOP HOUSE PERMATA JUNCTION BLOK B A-15 JABABEKA 1 CIKARANG 021-89846023/24| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 854 1962 KLINIK & APOTEK KEMALA JL. TARUM BARAT 2, RUKO GRAND ARTHA NIAGA 2 BLOK O2 NO. 23 - 23A 021-29083377 - 29083376| 021- N Y RB,PHAR JL. RAYA IMAM BONJOL, NO.74, RT.07/04, DESA SUKADANAU,CIKARANG 855 0574 KLINIK BUDI LUHUR 021- 88327226/88320116| 021-88327226 Y Y ALL COVERAGE BARAT 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 858 2510 MITRASANA TAMAN ASTER RUKO TAMAN ASTER KAV. A3 NO. 41 TELAGA ASIH CIKARANG BARAT 88333364| - N Y RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 859 0263 RB & KLINIK YAYASAN BINA MEDIKA KP. KONGSI, CIKARANG 021-8900050; 021-8900051|021-8900051 021-8900051 Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 860 0406 KLINIK ANNISA II (CIKARANG) JL. CIBARUSAH RUKO POIN, NO.31 R 021-8976189| - N Y RB,PHAR 021-8971643021-89110011|021- 861 0738 RS. AMANDA CIKARANG SELATAN JL. RAYA SERANG NO.83 CIKARANG SELATAN 021-8970808 Y Y ALL COVERAGE 89110011 RS. PERMATA KELUARGA LIPPO CIKARANG d/h 862 0660 JL. MH.THAMRIN KAVLING 129 LIPPO CIKARANG 021-8990 5588/ 8990 1927| 02189901860/89901902 Y Y ALL COVERAGE RS Harapan RS HARAPAN KELUARGA (d/h RS.HARAPAN 863 1041 JL.KASUARI RAYA KAV.1A-1B, KOTA JABABEKA, CIKARANG BARU 021-89840745|- 021-89835839 Y Y ALL COVERAGE INTERNASIONAL) KLINIK BERKAT MELIMPAH JABABEKA (HOSANA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 864 0850 JL. KAWASAN INDUSTRI I, JABABEKA B8, CIKARANG UTARA 021-8937941021-8937942|021-8937942 021-8937942,89833055 N Y MEDIKA II) 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

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 867 0929 KLINIK RENNICHA PUTRA JL. RAYA CIKARANG CIBARUSAH NO 89 LIPPO CIKARANG 021-8971852021-8971658|021-8971658 021-8971852 N Y RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 868 0966 RB & KLINIK CENTRAL MEDIKA JL. PILAR - SUKATANI, DS SUKARAYA NO 84, KARANG BAHAGIA 021- 89111103-|- 021-89119714 N Y RB,PHAR 021-89831945/7004236021- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 869 0967 CITRA ARDHITA MEDIFARMA CAPITOL BUSINESS PARK, BLOK B2, JL. NIAGA RAYA 02189831946/89833385 N Y 89831946|021-89831946 RB,PHAR RUKO CIKARANG CENTRAL CITY, BLOK H 29-30 KEL.CIANTRA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 870 1119 KLINIK SAPTA MITRA CIKARANG 021-8975369| 021-8975369 N Y KEC.CIKARANG SELATAN KAB.BEKASI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 871 1218 KLINIK CIKARANG MEDIKA JAYA JL. YOS SUDARSO NO.27 CIKARANG 021-8900129; 8901318| 021-8901318 N Y RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 872 1415 RB & KLINIK PERMATA BUNDA FUDHOLI JL. KH.FUDHOLY NO 11 KARANG ASIH, CIKARANG UTARA 021-89106080| - Y Y RB,PHAR KLINIK KASIH ANUGERAH SERANG BARU JL. RAYA SERANG-CIBARUSAH KP.BUNISARI RT.07/04 DS.SUKARAGAM 021-89952605,89952612021- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 873 1064 021-89951205 N Y (HOSANA MEDIKA C SERANG BARU 89952612|021-89952612 RB,PHAR 874 1067 RS. MEDIROSSA JL. INDUSTRI TEGAL GEDE - CIKARANG SELATAN 021-89833216| 021-8934979 Y Y ALL COVERAGE JL. RAYA CIBARUSAH, KAMPUNG CIJAMBE, SUKADAMI, CIKARANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 875 1514 KLINIK SUMBER WARAS 021-8970524| 021-8970524 N Y SELATAN RB,PHAR JL. N. PERUM VILA MUTIARA, KAMPUNG KUKUN CIKARANG NO.115 GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 876 1567 RB & KLINIK PUTRA MEDIKA 021-89677215; 02189677628| 021-89677216 Y Y RT.012/06 DS.CIANTAR RB,PHAR JL. RAYA CIKARANG CIBARUSAH KM. 28 RT. 012/006 DESA CIANTRA KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 877 4759 KLINIK PUTRA MEDIKA 2 (021)8971612| - N Y CIKARANG SELATAN RB,PHAR 021 8904160-64 / EXT 878 0275 RS. SENTRA MEDIKA CIKARANG JL. RAYA INDUSTRI PASIR GOMBONG JABABEKA, CIKARANG 021-8904159,89111112 Y Y ALL COVERAGE 225/081297102702| GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 879 0916 RB & KLINIK GRAHA BINA HUSADA JL. INDUSTRI SELATAN NO.1A, BLOK NN 3A, INDUSTRI JABABEKA II 021-89836243-|- 021-89836244 Y Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 882 6474 KLINIK ALFARMA KP.KAUM LEBAK NO.101 RT 04/02 SIMPANGAN, CIKARANG UTARA (021) 89323270| (021) 8905376 N Y RB,PHAR SHOPHOUSE BLOK A NO.14-15, 28-29 JABABEKA I KAWASAN INDUSTRI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 883 1719 CMC CLINIC ( CIKARANG MEDICAL CENTER ) 021-8934371| 021-8934035 N Y CIKARANG RB,PHAR OASIS KAV.1 JL. RAYA CIBARUSAH KEL. SUKARESMI, KEC. CIKARANG 884 4670 RS. OMNI CIKARANG (021) 2977 9999| 021-2977 9911 Y Y ALL COVERAGE SELATAN, BEKASI JL. RAYA RENGAS BANDUNG NO.20 001/003,KARANG SAMBUNG,KEDUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 885 3992 KLINIK CENTRAL MEDIKA 3 021-89142220| 021-89142221 N Y WARINGIN,BEKASI RB,PHAR 886 1308 RS. RIDHOKA SALMA JL. IMAM BONJOL NO.7 GARDU SAWAH 021-89116527| 021-89116528 Y Y ALL COVERAGE JL. KH. FUDHOLI NO.50 RT.01/04 DS. KARANG ASIH KEC. CIKARANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 887 2742 KLINIK SUMBER SEHAT CIKARANG (021) 8900566 / 89106020| (021) 8900566 N Y UTARA 17530 RB,PHAR GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 888 1287 RB & KLINIK NIZA ASYIFA BERSAMA 1 PERUMAHAN TELAGA HARAPAN BLOK E1 NO.1 CIKARANG BARAT 021-89109638| 021-89109638 Y Y RB,PHAR (021) 89105057 / 087717188000 / GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 889 4032 RB & KLINIK RIA PILAR JL. GATOT SUBROTO NO. 67 (021) 8900487 Y Y 085669228852| RB,PHAR KLINIK 24 JAM & HARAPAN SEHAT MEGA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 890 5118 JL. RAYA MEGA REGENCY PERUM MEGA REGENCY BLOK I NO 3 021-29370936| 021-883366721 N Y REGENCY RB,PHAR RUKO TELAGA HARAPAN BLOK F NO.16, PERUMAHAN TELAGA HARAPAN, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 891 1034 KLINIK HARAPAN SEHAT II 021-8904519-|- - N Y CIKARANG BARAT RB,PHAR KLINIK 24 JAM & RB. PERMATA BUNDA GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 892 2462 RUKO GRAMA NIAGA H2 NO. 15/15A, KARANG ASIH - CIKARANG UTARA 021 - 2928 2165, 021 - 2928 2166| - Y Y CIKARANG RB,PHAR JL. VILA MUTIARA CIKARANG, RUKO PASADENA BLOK RA NO. 3, 5, 6 893 2058 RSIA. GIZAR 021-89677240 / 89677204| 021-89677239 Y Y ALL COVERAGE CIANTRA, CIKARANG SELATAN 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 JL. PERUM KOTA SERANG BARU, KP. GEBANG DS. SUKARAGAM KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 896 2975 KLINIK PUTRA MEDIKA 3 (021) 89950333| - N Y SERANG BARU, BEKASI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 897 1824 KLINIK BUNDA AULIA JL. HAJI RATIM NO. 143 DS JATIWANGI CIKARANG BARAT - BEKASI 021-8998 3742 / 2897 3209| 021-8998 3742 N Y RB,PHAR JL. RAYA SERANG - CIBARUSAH RT 01/ RW 01 SERANG KEC.CIKARANG 898 2061 RS. BUDI ASIH CIKARANG 021 - 89677795| 021-89677402 Y Y ALL COVERAGE SELATAN,BEKASI 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 903 3610 PRODIA CIMAHI JL. JEND. AMIR MAHMUD NO. 523, CIMAHI 40523 (022) 6658125| N Y 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 0231-207351, 4856540231-485654|0231- 907 1091 RS. PUTERA BAHAGIA JL. CIREMAI RAYA NO.114 ,PERUMNAS 0231-486356/482328 Y Y ALL COVERAGE 485654 908 1029 RS. SUMBER WARAS CIWARINGIN JL. URIP SUMOHARJO, NO.5, CIWARINGIN 0231-342297/341079,3300888,341079-|- 0231-342112 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 909 3677 PRODIA CIREBON JL. R.A. KARTINI NO. 32, CIREBON 45122 (0231) 208989| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 910 2690 KIMIA FARMA 40 (BM CIREBON) JL. PARUJAKAN NO.12 , 0231-208954| - N Y 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 0231-224646; 25121730231- 912 0602 RS. PERTAMINA CIREBON JL. PATRA RAYA, KLAYAN 0231-224795; 209328 Y Y ALL COVERAGE 224646|0231-224646 913 1316 RS. MITRA PLUMBON JL. RAYA PLUMBON, KM.11 0231-324483/323100| 0231-322355/322066 Y Y ALL COVERAGE 0231-208948/208680 / 0231-2056570231- 914 0293 RS. PELABUHAN CIREBON JL. SISINGAMANGARAJA, NO.45 0231-234670 Y Y ALL COVERAGE 205657|0231-205657 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 917 2180 APOTEK FARMARIN CIREBON JL. KESAMBI RAYA NO. 92 A 08179416709| - N Y RB,PHAR 918 3882 RSIA. CAHAYA BUNDA JL. RAYA PERJUANGAN NO.8 KESAMBI CIREBON 0231-8333388 / 99| 0231-482121 Y Y ALL COVERAGE

DEPOK JL. ALTERNATIF CIBUBUR CILEUNGSI NO. 8 C-D, DEPOK, JAWA BARAT GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 919 2825 LAB. PRODIA CIBUBUR (021) 84598650, 84590656| (021) 84598651 N Y 16954 RB,PHAR 920 1194 RS. HASANAH GRAHA AFIAH JL. RADEN SALEH NO.42 DEPOK 021-77826267/ 77826276| 021-77833796 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 921 2630 KLINIK & APOTEK KF 202 JL. KEJAYAAN BLOK IX NO. 2, DEPOK 0217704044| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 922 1737 TELKOMEDIKA HEALTH CENTER (THC) DEPOK JL. RAYA KARTINI NO. 17RT. 02 RW.09 DEPOK PANCORAN MAS 021-77219925| - N Y RB,PHAR 021-8710870/021-8718634/33|021- 923 0346 RS. TUGU IBU JL. RAYA BOGOR, KM.29, CIMANGGIS - DEPOK 021-8708266 Y Y ALL COVERAGE 8718634/33 924 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 RUKO PERMATA DEPOK BLOK A,5-6 SEKTOR MUTIARA KEL. PONDOK JAYA, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 926 4489 KLINIK PERMATA HATI (021) 77200935| - N Y CIPAYUNG, DEPOK RB,PHAR 021-8701873-74 / 021-8712300|021- 927 0777 RSIA. TUMBUH KEMBANG JL. RAYA BOGOR, KM.31, NO.23, CIMANGGIS 021-8701872 Y Y ALL COVERAGE 8712300 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 RUKO PESONA KHAYANGAN NO.9, JL. MARGONDA RAYA NO.45, DEPOK GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 930 2791 LAB. PRODIA DEPOK (021) 7751178, 7751826| - N Y 16411 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 932 2806 KLINIK PERTAMEDIKA CINERE JL. CINERE RAYA NO. 11B 021-7535022| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 933 2808 KLINIK PERTAMEDIKA DEPOK ( MARGONDA) JL. MARGONDA RAYA NO. 270, DEPOK 021-77219363| 021-77219364 N Y RB,PHAR

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 934 4007 KLINIK UTAMA RAWAT INAP LIMO MEDICARE JL. MERUYUNG RAYA NO. 70, PANCORAN MAS, DEPOK (021) 77888674; 77888675| (021) 77888675 N Y RB,PHAR JL. ALTERNATIF KM 1 RUKO CIBUBUR POINT BLOK A6-8 HARJAMUKTI, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 935 4383 KLINIK TUMBUH KEMBANG 021-8443316, 8443004| 021-8443018 N Y CIMANGGIS DEPOK RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 936 3329 KLINIK AL-ZAMZAM JL. ABDUL GANI NO. 53, CILODONG, DEPOK (021) 77841431; 87904855| (021) 87904855 N Y RB,PHAR 937 1056 RS. BUNDA MARGONDA JL. MARGONDA RAYA NO.28 PONDOK CINA-DEPOK 16424 021-78890551|- 021-78889958 Y Y ALL COVERAGE GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 938 1318 RB & KLINIK CITAMA CIPAYUNG JL. RAYA CIPAYUNG NO.27 PANCORAN MAS DEPOK 021-87989203/5-021-87982268| 02187986666/8282869 Y Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 939 2090 KLINIK QITA JL. SEDAP MALAM RAYA NO. 5 KOMP. PERTANIAN DEPOK, CITAYAM 021-87989096| - N Y RB,PHAR JL. ARIF RAHMAN HAKIM SIMPANG 3 MARGONDA NO. 7 KEL DEPOK, KEC GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 940 2078 APOTIK FARMARIN V DEPOK 021-7757117| 021-29402214 N Y PANCORAN MAS DEPOK RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 941 1950 KLINIK & APOTEK KF 143 JL. MARGONDA DEPOK 021-7522997| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 942 1736 KJP MEDICAL CENTER JL. KEJAYAAN BLOK IX NO 4 SUKMAJAYA, DEPOK TIMUR 021-7703925, 7714605| 021-7703927 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 943 1776 KLINIK UTAMA RAWAT INAP NAURA MEDIKA JL. KEMAKMURAN RAYA NO 37 DEPOK II 021-77827515| 021-77824756 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 944 2219 KLINIK CITRA INSANI JL. RAYA PENGASINAN NO. 5 SAWANGAN DEPOK 0251-8604733/8611507| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 945 2629 KIMIA FARMA BEJI JL. RAYA NUSANTARA - DEPOK 02177207404| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 946 2627 KLINIK & APOTEK KF 352 JL. MARGONDA RAYA, DEPOK 02178884611| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 947 2628 KLINIK & APOTEK KF 394 JL. SILIWANGI NO.35, DEPOK 02177214567| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 948 2460 KLINIK UTAMA TUGU SAWANGAN JL. RAYA MUCHTAR NO. 20 RT.002/007 SAWANGAN - DEPOK 16511 0251-8613433/021-29420173| 0251-8613433 N Y 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 GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 957 1266 RB & KLINIK EL RAPHA JL. RAYA BOGOR KM 30 CIMANGGIS - DEPOK 021-8715082/87720327| 021-8715082 Y Y RB,PHAR GARUT GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 958 2358 KLINIK MAHESA JL. CIMANUK NO.8 0262-233238| - N Y RB,PHAR 959 4039 RS. NURHAYATI JL. SUDIRMAN NO. 6 GARUT 0262-238966| 0262-231824 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 960 2994 LAB. KIMIA FARMA GARUT JL. CIMANUK 11A PAMINGGIR (0262) 540077| (0262) 540077 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 961 2934 LAB. PRODIA GARUT JL. RAYA SAMARANG NO. 104, TAROGONG GARUT 0262-2246204| (0262) 2245204 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 962 2120 KLINIK PADJAJARAN LELES JL. RAYA LELES KEC.LELES KAB GARUT 0262-2458083| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 963 1627 BETHESDA MEDICAL CENTER GARUT JL. CIWALEN NO 43 GARUT 0262-242663,238735| 0262-242663 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 964 2699 KLINIK & APOTEK KF 377 JL. CIMANUK NO. 11A, GARUT 0262 233237| - N Y RB,PHAR INDRAMAYU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 965 4126 LAB. PRODIA INDRAMAYU JL. RAYA PAKANDANGAN ( DEPAN GRIYA ASRI I ) BUNDERAN MANGGA 0234-275065| - N Y RB,PHAR KARAWANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 966 5434 KLINIK AR-RAHMAN JL. RAYA PERURI NO. 07, TELUK JAMBE TIMUR, KARAWANG (0267) 8458155| - N Y RB,PHAR JL. INTERCHANGE TOL KARAWANG BARAT NO.3 DS WADAS KEC. TELUK 967 2731 RS. ROSELA (0267) 8637207/8637205| 0267 8367205 Y Y ALL COVERAGE JAMBE RS. CITRA SARI HUSADA (D/H KLINIK INTAN 968 1006 JL. RAYA KOSAMBI-TELAGASARI, KM.3, KLARI, KARAWANG TIMUR 0267-437507/8617972| 0267-438681 Y Y ALL COVERAGE BAROKAH) 0267-433636/435527 - 0267- 969 1022 RSU. FIKRI MEDIKA JL. RAYA KOSAMBI- TELAGASARI, DS BLENDUNG , KLARI 0267-8615577/88 Y Y ALL COVERAGE 8615555/8615566 (KLINIK):|- 970 1409 RSU. PURI ASIH JATISARI JL. RAYA JATISARI NO.3 PASAR JATISARI 0264-361459/361466| 0264-8375276 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 971 0899 KLINIK AULIA KARAWANG JL. PURWASARI KM 6, PURWASARI - KARAWANG 0264-8286755/ 0811 1889279|- 0264-8286756 N Y RB,PHAR 972 4699 RSIA. SENTUL CIKAMPEK JL. A. YANI NO.16 SENTUL, CIKAMPEK SELATAN (0264) 8386671/ 8389060| (0264) 316096 Y Y ALL COVERAGE 0267-8643000/8641414/414245 / 414264 973 1133 RS. MANDAYA(D/H RS.CITO KARAWANG) JL. ARTERI TOL KARAWANG BARAT TELUK JAMBE 0267-414306 Y Y ALL COVERAGE / 8643002| JL. SYECH QURO NO. 4 KEL. PALUMBONSARI KEC. KARAWANG TIMUR KAB. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 974 6017 KLINIK LAMARAN 0267-8453951| 0267-8453951 N Y KARAWANG 41351 RB,PHAR JL. MELATI NO. 9A RT. 001/ 010, GURO II, KEL. KARAWANG WETAN, KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 975 4658 KLINIK INTERNA MEDIKA (0267) 845 2733 / 0812-8586 4765| 2678452733 N Y KARAWANG TIMUR, KARAWANG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 976 4683 KLINIK SEHAT BAHAGIA JL. PANATAYUDHA I NO. 57 A RT. 02 RW. 03 NAGASARI, KARAWANG (0267) 414 283| - N Y RB,PHAR JL. BELAKANG PASAR RT. 02/09 KEL. NAGASARI KEC. KARAWANG BARAT, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 977 4320 KLINIK SETYA MEDIKA (0267) 402025| (0267) 402025 N Y KARAWANG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 978 1310 KLINIK ANDINA KARAWANG JL. PANCAWATI, NO.5A, KLARI 0267-436568| 0267-438406 N Y 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 0267-401817/401818/4003510267- 980 0255 RS. BAYUKARTA JL. KERTABUMI, NO.44 0267-404472/401202 Y Y ALL COVERAGE 801818|0267-801818 GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 981 4319 KLINIK & RB NUR ANNISA JL. MANUNGGAL VII NO. 38 PALUMBONSARI, KARAWANG (0267) 405201| - Y Y RB,PHAR GEDUNG THE MANOR LT. 2, JL. SURYA UTAMA KAV.C-1, KAWASAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 982 4509 KLINIK KYOAI MEDICAL CENTER (021) 30424007/8/9| 021-30424010 N Y INDUSTRI SURYA CIPTA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 983 2993 KLINIK & APOTEK KF 79 KARAWANG JL. DEWI SARTIKA II NO.30 KARAWANG 0267-405748| 0267-405748 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 984 2801 LAB. PRODIA KARAWANG JL. KERTABUMI NO. 67 A, KARAWANG 41311. 0267- 403644; 412640| 0267-412640 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 985 3400 KLINIK GRAHA MEDIS CILAMAYA JL. CILAMAYA DS CILAMAYA KEC CILAMAYA WETAN 0264-340202| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 986 3369 APOTIK KIMIA FARMA 343 JL. KERTABUMI NO 12A KARAWANG JAWA BARAT 0267-8453321| - N Y RB,PHAR PERUM GRIYA KONDANG ASRI BLOK T NO. 01 DESA KONDANG JAYA KEC. GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 987 1835 KLINIK GRIYA MEDIKA 0267-8619999; 082112039999| 0267-8615309 N Y KLARI - KARAWANG TIMUR RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 988 1572 DHARMA DENTAL CLINIC (DDC) JL. KERTABUMI NO 62 KARAWANG 0267-8453633| 0267-403962 N Y RB,PHAR 0267-401475, 402855, 406445, 989 0083 RS. DEWI SRI JL. ARIF RAHMAN HAKIM, NO.1 0267-404010 Y Y ALL COVERAGE 402147|0267-402147 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 990 1635 KLINIK MITRA KONDANG UTAMA JL. PENGAIRAN CITRA KEBUN MAS KONDANG KARAWANG 0267-8402700/0267-8616923| 0267-8450001 N Y RB,PHAR JL. RONGGOWALUYO RT.02/05 DESA SUKAHARJA KEC. TELUKJAMBE 991 2741 RSIA. MITRA FAMILY-KARAWANG 0267 - 8458327 , 8458328, 8458329| - Y Y ALL COVERAGE TIMUR, KARAWANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 992 0690 KLINIK YAKESTI KARAWANG JL. RAYA KLARI, RT. 04 / 01, GINTUNGKERTA KLARI 0267-432416| 0267-432416 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 993 0691 KLINIK PURWA MEDIKA JL. RAYA TAMELANG NO.12 DESA MEKARJAYA, PURWASARI 0267-433653| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 994 0689 KLINIK MITRA SEHAT JL. KOSAMBI - CURUG NO.28, DUREN, KLARI 0267-8402061/433930| 0267-8402061 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 995 0704 KLINIK CITO KARAWANG JL. KERTABUMI, NO.29 0267-410173/415957| 0267-415957 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 996 0197 KLINIK GEMPOL JL. RANGGA GEDE NO.29, GEMPOL, TANJUNG PURA 0267-412117/8453903| 0267-8453903 N Y RB,PHAR 997 0869 RS. DELIMA ASIH SISMA MEDIKA JL. WIRASABA NO.54 JOHAR 0267-403073/8454248|- 0267-405598 Y Y ALL COVERAGE 0267-414520, 0267 - 414524, 998 1023 RS. ISLAM KARAWANG JL. PANGKAL PERJUANGAN KM.2 0267-413277 Y Y ALL COVERAGE 4145210267-414524|0267-414524 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 999 1027 KLINIK BINA MEDIKA KARAWANG JL. RAYA TELUK JAMBE NO 8, SUKA GALIH, TELUK JAMBE TIMUR 0267-641968 / 08121918055-412117|- 0267 - 641968 N Y RB,PHAR JL. PROKLAMASI NO. 15 KW 8 RT 003 RW. 005 KEL. TUNGGAKJATI KEC GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1000 1035 KLINIK MITRA GEMPOL 0267- 8451114-|- - N Y KARAWANG BARAT KAB. KARAWANG, RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1001 0095 KLINIK GRAHA MEDIS JL. RAYA KOSAMBI, NO.23, DUREN KLARI, KARAWANG TIMUR 0267-435527| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1003 1059 KLINIK PURI ASIH TELUKJAMBE JL. PERURI NO. 99 PINAYUNGAN, TELUK JAMBE, KARAWANG TIMUR 0267-646845|- 0267-646845 N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

KUNINGAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1005 3763 PRODIA KUNINGAN JL. ACHMAD YANI NO. 39, KUNINGAN 45511 (0232) 876839| - N Y 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 JL. RAYA JOMBOL-DAWUAN RT. 01/05, KECAMATAN DAWUAN, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1008 3658 PRODIA CIDERES (0233)6645488| - N Y MAJALENGKA 45452 RB,PHAR PURWAKARTA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1009 3765 PRODIA PURWAKARTA JL. VETERAN NO.96, PURWAKARTA (0264) 8222 633| - N Y 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 JL. RAYA INDUSTRI KP. MARACANG RT. 07/02 DESA MARACANG KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1011 5986 KLINIK ANNISA (0264) 822 2596| N Y BABAKANCIKAO, PURWAKARTA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1012 5987 KLINIK ANNISA 2 JL. PRAMUKA NO. 107 DESA BUNDER KEC. JATILUHUR PURWAKARTA (0264) 822 0201| N Y 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 JL VETERAN RT. 031/004, KEL. NAGRI KALER, KEC.PURWAKARTA, JAWA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1014 4763 KLINIK SPESIALIS SILOAM PURWAKARTA 0264-8628901| - N Y BARAT 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1016 4443 KLINIK MITRA MEDIKA PURWAKARTA JL. MR. DR. KUSUMAATMAJA NO. 13, KEL. CIPAISAN, PURWAKARTA (0264) 8624195| - N Y RB,PHAR JL. VETERAN NO 152 KEL NAGRI KALER PURWAKARTA ( DEPAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1017 2698 KLINIK & APOTEK KF PURWAKARTA 0264 8227437| - N Y INSPECTORAT ) RB,PHAR 1018 1545 RS. MH THAMRIN PURWAKARTA JL. BUNGURSARI, NO.36 0264-8222222| 0264-8222223 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1019 1315 KLINIK MIRACLE GROUP KOMP. ANEKA JASA BLOK AII NO.9-10 KOTA BUKIT INDAH 0264-35166, 351377| 0264-351355 N Y RB,PHAR 1020 1057 RSIA. ASRI PURWAKARTA JL. VETERAN CIHIDEUNG NO.15 PURWAKARTA 0264-211680; 8223161; 0811117031|- 0264-219047 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1021 0759 KLINIK MEDIKA SEHAT JL. IPIK GANDAMANAH SUKAMULYA 0264-8225017| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1022 0189 KLINIK AQMA PURWAKARTA JL. IBRAHIM SINGADILAGA, NO.14 0264-200377| 0264-200377 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1024 1175 KLINIK AQMA PLERED JL. ANJUN NO.96 PLERED 0264-270830| 0264-270830 N Y RB,PHAR JL. RAYA SADANG SUBANG, KM 5, KP. KIARA DUA, DS. CIKUMPAY, KEC. 1025 1620 RS. BHAKTI HUSADA II PURWAKARTA 0264-8225344/8225345/081373360783| 0264-8225255 Y Y ALL COVERAGE CAMPAKA RS. KARINA MEDIKA PURWAKARTA D/H 1026 4054 KP.KRAJAN RT. 01/01 MARACANG, BABAKAN CIKAO (0264) 8220544| (0264) 8623240 Y Y ALL COVERAGE MASITHOH SUBANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1027 2752 KLINIK MITRA ABADI JL. KAPTEN HANAFIAH NO.3 RT. 98 RW. 27 KEL. KARANGANYAR, SUBANG 0260-418247| 0260-418237 N Y RB,PHAR INHOUSE CLINIC PT. DAHANA (KLINIK MITRA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1028 4325 JL. RAYA SUBANG, CIKAMURANG KM.12 CIBOGO -SUBANG (0260) 742 3333| (0260) 742 3888 N Y ABADI) RB,PHAR 0260- 1029 0191 RS. PERKEBUNAN NUSANTARA 8 SUBANG JL. OTTO ISKANDAR, NO.1, SUBANG 0260-420391 Y Y ALL COVERAGE 420406,411632,420306,420436|0260- SUKABUMI RS. KARTIKA KASIH (D/H RS.KARTIKA MEDICAL 1030 1506 JL. JEND. A.YANI, NO.18 0266-6250902/6250905/6250904| 0266-6250901 Y Y ALL COVERAGE CENTER) 1031 3448 RS. RIDOGALIH JL. GUDANG NO. 24 SUKABUMI 0266-221983| 0266-216161 Y Y ALL COVERAGE 0266- 1032 0056 RS. ISLAM ASSYIFA JL. JEND. SUDIRMAN, NO. 27 0266 - 213433/22350 Y Y ALL COVERAGE 222663/218672/241463/223742/2237420 1033 0832 RS. HERMINA SUKABUMI JL. RAYA SUKARAJA RT.003/03, SUKARAJA 0266-6252525/6249292| 0266-235020 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1034 6016 KLINIK PERMATA SUKABUMI JL. RA. KOSASIH NO.112 RT.02/16 CISARUA, CIKOLE (0266) 219188/6245414| (0266) 6247781 N Y 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 JL. KOLONEL AHMAD SYAM RT 04 RW 02 DESA SAYANG KEC. JATINANGOR - GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1038 2122 KLINIK PADJADJARAN JATINANGOR 022 -7781900| - N Y BANDUNG 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1040 3786 PRODIA SUMEDANG JL. P. GEUSANULUN NO. 111, SUMEDANG 45312 (0261) 201259| - N Y RB,PHAR TASIKMALAYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1041 2106 KLINIK & APOTEK KF 404 JL. R.A MARTADINATA NO. 87 TASIKMALAYA 0265-340515| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1045 2096 KLINIK & APOTEK KF 195 JL. SUTISNA SENJAYA NO. 191 TASIKMALAYA 0265-311225/311224| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1051 2935 LAB. PRODIA TASIKMALAYA JL. RE MARTADINATA NO 9 0265-2353080| - N Y RB,PHAR JAWA TENGAH

BANYUMAS

1052 3171 RSU. WIRADADI HUSADA JL. MENTERI 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1054 3276 LAB. PRODIA BOYOLALI JL. PANDANARAN NO. 252, BOYOLALI 08122895310| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1061 3268 LAB. PRODIA CEPU JL. PEMUDA NO. 41 B, CEPU 082331833027| - N Y RB,PHAR 1062 1438 RS. MUHAMMADIYAH CEPU JL. RONGOLAWE, NO.137 0296-421727| 0296424678/424569 Y Y ALL COVERAGE

CILACAP GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1063 3526 KLINIK PRATAMA KIMIA FARMA CILACAP JL. GATOT SUBROTIO NO. 59 CILACAP 0282-535293| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1066 2696 KLINIK & APOTEK KF 89 JL. GATOT SUBROTO NO.59, CILACAP 0282 535293| - N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1068 1005 KLINIK DR TUTUK JL. PERINTIS KEMERDEKAAN 21 0282-545921-|- - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1074 3269 LAB. PRODIA JEPARA JL. MH. THAMRIM NO. 14 JEPARA 0291598808| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1081 3163 LAB. PRODIA KUDUS JL. WAHID HASYIM NO.75, KUDUS -| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1083 3259 LAB. CITO (JL. AKBP AGIL KUSUMADYA NO. 7 ) JL. AKBP AGIL KUSUMADYA NO. 7 0291-4251979| - N Y RB,PHAR MAGELANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1084 3286 LAB. CITO MAGELANG JL. TENTARA PELAJAR NO 126 MAGELANG 0293 363763| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1085 3161 LAB. PRODIA MAGELANG JL. AHMAD YANI NO.36 A, MAGELANG 0293-364323| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1092 3227 LAB. CITO PEKALONGAN JL. K.H. MANSYUR NO.33 PEKALONGAN 0285-422458| 0285-422458 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1093 2694 KLINIK & APOTEK KF 16 JL. IMAM BONJOL, NO.16 A, PEKALONGAN 0285-421402| 0285-423322 N Y RB,PHAR JL.PELITA II RT.05/RW.02, BUARAN KRADENAN KEL. BUARAN KRADENAN 1094 5665 RSU. H.A DJUNAID (0285) 436325/ 4410660| (0285) 436326 Y Y ALL COVERAGE KEC. PEKALONGAN SELATAN 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1099 3277 LAB. PRODIA PURBALINGGA JL. LETJEND SUPRAPTO NO. 17 B, PURBALINGGA 08112616123| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1105 3131 LAB. CITO PURWOKERTO JL. PRAMUKA 798 RT 7/1 PURWOKERTO 0281-637362; 637538| 0281-637583 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1106 2095 KLINIK & APOTEK KF FAJAR SEHAT JL. R.A WIRIATMAJA NO. 37 PURWOKERTO 0281-637247| 0281-640760 N Y RB,PHAR 1107 3250 RS. ISLAM PURWOKERTO JL. HAJI MANSYURI NO.39 PURWOKERTO 0281-630019| -0281-635394 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1108 2094 APOTEK KIMIA FARMA 133 PURWOKERTO JL. JEND. SUDIRMAN TIMUR NO. 435 0281-638546| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1109 2204 LAB. PRODIA PURWOKERTO JL. LETJEN S.PARMAN NO:946 A, PURWOKERTO 0281-642448| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1114 3272 LAB. PRODIA PURWOREJO JL. JENDRAL AHMAD YANI NO. 22 B PURWOREJO 081914336261| - N Y RB,PHAR SALATIGA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1115 3350 APOTEK KIMIA FARMA SALATIGA JL. BRIGJEN SUDIARTO NO. 30 SALATIGA 0298-325350| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1116 3160 LAB. PRODIA SALATIGA JL. BRIGJEND.SUDIARTO NO.18 A, SALATIGA 50721 0298311371| - N Y RB,PHAR 1117 1145 RS. PURI ASIH JL. JEND. SUDIRMAN NO.169 0298-323209/0298-312049| 0298-322898/311466 Y Y ALL COVERAGE

SEMARANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1118 2693 KLINIK & APOTEK KF 71 JL. DR. NO.3 , SEMARANG 024 3520763| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1120 3261 KIMIA FARMA 153 (JL. JATI RAYA BANYUMANIK) JL. JATI RAYA BANYUMANIK, SEMARANG 024-7464268| 024-7464268 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1121 3262 KIMIA FARMA 259 (JL. FATMAWATI) JL. FATMAWATI NO. 42, SEMARANG 024-76928544| 024-76928544 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1122 3264 KIMIA FARMA 271 MEDITAMA (JL. AHMAD) JL. KH. AHMAD DAHLAN NO. 9, KEL. BENDUNGAN, KEC. GAJAHMUNGKUR 024-8455323| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1123 3265 KLINIK & APOTEK 324 (JL. RAYA NGALIAN) JL. RAYA NGALIYAN , KEL. TAMBAK AJI, KEC.NGALIYAN SEMARANG 024-7612049| - N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1131 2246 APOTEK KIMIA FARMA 17 JL. TENTARA PELAJAR NO. 16 A, SEMARANG 024-8447245| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1132 2168 APOTEK FARMARIN SEMARANG JL. KALIGARANG NO. 2D 024-8450558| 024-8450558 N Y 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 JL. GUNUNG SAWO NO. 21 RT.08 RW. 04, KEL. PETOMPON, KEC. 1135 4457 RSIA GUNUNG SAWO 024-8315171| (024) 8412320; Y Y ALL COVERAGE GAJAHMUNGKUR, SEMARANG JL. TLOGOSARI RAYA NO. 1 KAV. 2, KEL. TLOGOSARI KULON, KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1136 3267 KIMIA FARMA 374 (JL. TELOGO SARI) 024-6709192| - N Y PEDURUNGAN, SEMARANG RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1137 3349 APOTEK KIMIA FARMA 203 UNGARAN JL. DIPENOGORO 212 UNGARAN 024-76914353| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1138 3260 KIMIA FARMA 19 (JL. SULTAN AGUNG) JL. SULTAN AGUNG KOMPL. PERTOKOAN R A/15 SEMARANG 024-8315248| 024-8315795 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1139 3162 LAB. PRODIA SEMARANG (JL. JEND SUDIRMAN ) JL. JENDRAL SUDIRMAN NO.121 SEMARANG 024-7621757| - N Y RB,PHAR 1140 3215 RS. WILLIAM BOOTH SEMARANG JL. S. PARMAN NO. 5 SEMARANG 024-8411800| Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1141 2692 KIMIA FARMA 178 JL. BRIG.SUDIARTO,462 E (MAJAPAHIT LAMA) 024 6716235| -- N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1145 3217 KLINIK KITA TEMBALANG (DR MOEZ) JL. NGESREP TIMUR 5/36 BANYUMANIK, SEMARANG 024-7472220 / 085640398938| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1146 2238 KLINIK & APOTEK KF 18 JL. PEMUDA NO. 135 SEMARANG 024-3545101/3541510/3518913| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1150 3218 KLINIK KITA KALIPANCUR (DR MOEZ) JL. ABDULRAHMAN SALEH KAV. 783 KALIPANCUR, SEMARANG 024-7624455/ 085641869731| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1151 3243 LAB.PRODIA SETIABUDI SEMARANG RUKO SETIABUDI NO.8 JL. SETIABUDI 119 D 024-7479369/081390967979| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1152 3245 LAB. CITO (JL. INDRAPRASTA NO. 81 A) JL. INDRAPRASTA NO. 81 A SEMARANG 024-3556853| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1153 3246 LAB. CITO ( JL. SETIABUDI ) JL. SETIABUDI NO.120 A 024-7461645| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1154 3247 LABORATORIUM KLINIK CITO ( JL. DR. CIPTO ) JL. DR.CIPTO NO.14 A 024-3515374| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1155 4373 KLINIK RAFAEL JL. PLAMPITAN NO.33, SEMARANG (024) 3513888| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1156 3230 KLINIK KITA KEDUNGMUNDU (DR MOEZ) JL. KEDUNGMUNDU RUKO GRAHA WAHID NO. 7, SEMARANG -| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1157 3231 KLINIK IBNU SIENA PUSPONJOLO JL. PUSPONJOLO TENGAH RAYA NO.65 024-7609338| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1158 3232 KLINIK IBNU SIENA NGALIYAN JL. PROF RUKO SEGITIGA EMAS B-7 024-76674346| - N Y RB,PHAR SLAWI

1159 1665 RSU. ADELLA JL. PROF MOH YAMIN NO. 77 SLAWI 0283-491154/491773| 0283-491354 Y Y ALL COVERAGE

SOLO GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1160 3307 KLINIK & APOTEK KF 63 SOLO JL. ADISUCIPTO NO. 70 SURAKARTA 0271-718014| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1161 3279 LAB. CITO SOLO JL. YOSODIPURO NO.64 SURAKARTA 0271-2500055| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1164 3354 APOTEK KIMIA FARMA YOSODIPURO 252 JL. NO.111B, SOLO -| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1165 3280 LAB. KLINIK KIMIA FARMA SURAKARTA JL. ADISUCIPTO NO. 70 SURAKARTA 0271-727886| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1171 2181 APOTEK FARMARIN SOLO JL. GREMET NO.3 RT 007/11 MANAHAN 085727427423| - N Y RB,PHAR 1172 0118 RS. DR. OEN SOLO BARU KOMP. PERUMAHAN SOLO BARU, GROGOL, SUKOHARJO 0271-620220| 0271-622555/660935 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1173 2373 KLINIK PRODIA SOLO JL. RONGGOWARSI. TO NO. 143 SOLO 57131 0271-646378| 0271-638779 N Y RB,PHAR 1174 2907 RS. HERMINA SOLO JL. KOL SUTARTO NO. 16 JEBRES SOLO 0271-638989| 271 Y Y ALL COVERAGE

SRAGEN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1175 3275 LAB. PRODIA SRAGEN JL. KOLONEL SUGIYONO NO. 8, WIDORO, SRAGEN 0271-890263| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1176 3353 APOTEK KIMIA FARMA 212 - SRAGEN JL. SUKOWATI NO.440A, SRAGEN MANGGIS 0271-892209| - N Y RB,PHAR SUKOHARJO GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1177 3355 APOTEK KIMIA FARMA SUKOHARJO JL. VETERAN NO.11 SUKOHARJO 0271-590411| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1181 3220 LAB. CITO TEGAL JL. GAJAH MADA NO. 79 TEGAL 0283-353402| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1182 2093 APOTEK KIMIA FARMA 97 TEGAL JL. MAYJEN SUTOYO NO. 44 TEGAL 0283-35473| 0283-3355765 N Y RB,PHAR 1183 1540 RS. MITRA KELUARGA TEGAL JL. SIPELEM, NO.4, KEMANDUNGAN, TEGAL BARAT 0283-340399/ 340999| 0283-340902 Y Y ALL COVERAGE 0283-355717 /0283-359900 / 0283- 1184 0753 RS. ISLAM HARAPAN ANDA JL. ABABIL NO.42 0283-351263 Y Y ALL COVERAGE 358244| TEMANGGUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1185 4519 PRODIA TEMANGGUNG RUKO PANDEAN, JL MT. HARYONO - TEMANGGUNG 0293-4960160| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1188 3274 LAB. PRODIA WONOGIRI JL. JEND. ACHMAD YANI NO. 58 WONOGIRI 08122583522| - N Y RB,PHAR WONOSOBO GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1189 4127 LAB. PRODIA WONOSOBO JL. KAUMAN NO. 15, WONOSOBO ( PERTIGAAN MANGLI ) 0286-325275| - N Y RB,PHAR

Page 17 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1192 3841 APOTEK KIMIA FARMA TRUNOJOYO 419 JL. TRUNOJOYO NO.75A BANGKALAN 0313095459| 313095459 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1193 3840 APOTEK KIMIA FARMA 163 JL. JOKOTOLE NO.5 BANGKALAN 0313091016| 313091016 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1201 5908 LAB. PRODIA BLITAR JL MAWAR NO 82/74 KEL/KEC. SUKOREJO KOTA BLITAR 0342-803179| 0342-803179 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1206 3842 KLINIK & APOTEK KF 164 (BM GRESIK) JL. R.A KARTINI NO.150-152 0313984783| 313984783 N Y RB,PHAR 1207 3648 RSUD. IBNU SINA KAB. GRESIK JL. DR. WAHIDIN SH NO.243B, GRESIK 031-3951239| - Y N H&S,MAT 031- 1208 1427 RS. PETROKIMIA GRESIK (JL JEND SUDIRMAN) JL. JEND. A.YANI NO.69 031-3980008/3981232 Y Y ALL COVERAGE 3988877/3990994/3978658/3977666| 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1212 4966 KLINIK MEDIS PUSURA MENGANTI RUKO MENGANTI MAS BLOK U-2, JL RAYA BRINGKANG, MENGANTI, GRESIK 031-5471707| - N Y 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 0331- 1216 0725 RS. PERKEBUNAN (PTPN) X JEMBER JL. BEDADUNG, NO.2 0331-485912 Y Y ALL COVERAGE 487104,485415,426873,485912,41074803 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1217 2077 KLINIK & APOTEK KF 241 JEMBER JL. PANGLIMA SUDIRMAN NO. 46 JEMBER 0331-489885| - N Y RB,PHAR RSU. KALIWATES PT PERKEBUNAN NUSANTARA 0331- 1218 1685 JL. DIAH PITALOKA NO 1 JEMBER 0331-489100 Y Y ALL COVERAGE XII 3137525/483567/488964/485967/489100 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1219 2342 THC JEMBER JALAN LETJEN SUPRAPTO NO. 65 JEMBER 0331-339725| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1222 2076 KLINIK & APOTEK KF 62 JEMBER JL. GAJAH MADA 171 JEMBER 0331-489020| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1229 1998 KLINIK & APOTEK KF 75 KEDIRI JL. JAKSA AGUNG SUPRAPTO NO. 25 KEDIRI 0354-773384/ 694913| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1232 3828 APOTEK KIMIA FARMA SMAN II PARE JL. PAHLAWAN KUSUMA BANGSA 28 PARE 0354-390006| 0354-390006 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1234 3612 PRODIA KEDIRI JL. KARTINI NO. 18, KEDIRI 64123 (0354) 698960| (0354) 698961 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1237 6376 KLINIK SURYA KEDIRI JL. TUNGGUL WULUNG NO.15 KARANGREJO, NGASEM 085216577778| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1238 2075 KLINIK & APOTEK KF 151 KEDIRI JL. STASIUN NO. 47 KEDIRI 0354-694913| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1245 3425 KLINIK & APOTEK KF 76 JL. JAWA NO.14 0351-453381| 0351-453381 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1249 2345 THC MADIUN JALAN MANGGIS NO.9, MADIUN 0351-77542120| 0351-476697 N Y RB,PHAR

Page 18 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1256 2274 KLINIK & APOTEK KF 53 JL. KAWI NO.22 A MALANG 0341 362 301/ 364 056| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1261 3815 KIMIA FARMA NO.245 BATU JL. DIPONEGORO NO. 93 BATU MALANG -| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1262 3816 KIMIA FARMA NO. 210 MALANG JL. TUMENGGUNG SURYO NO. 25 MALANG 0341423930| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1263 3817 KIMIA FARMA NO. 187 MALANG JL. M.T. HARYONO NO. 110 MALANG 0341553283| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1264 3818 KIMIA FARMA NO. 150 MALANG JL. SELAT SUNDA 1 D NO. 25 MALANG 0341713091| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1265 3820 KIMIA FARMA NO. 36 MALANG JL. IJEN NO. 88 MALANG 0341359677| 341359678 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1266 3164 LAB. PRODIA MALANG JL. MERBABU NO.10, MALANG 0341-366042| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1267 2680 KIMIA FARMA 116 JL. LA SUCIPTO /148,MALANG 0341-489539| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1272 3814 KIMIA FARMA 453 SUTOYO MALANG JL. LETJEN SUTOYO NO. 107 MALANG 0341478382| - N Y RB,PHAR 1273 0609 RS. PANTI NIRMALA JL. KEBALEN WETAN, NO.2-8 0341-362459| 0341-327930 Y Y ALL COVERAGE 0341-325249 / 3570341 / 341357|0341- 1274 0125 RSIA. MELATI HUSADA JL. KAWI, NO.32 0341-365094/341357 Y Y ALL COVERAGE 341357 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1275 4740 MALANG EYE CENTER JL. DR. CIPTO NO. 3 (0341) 341666| - N Y RB,PHAR 0341-594161 /0341-598192/5|0341- 1276 0192 RS. BAPTIS BATU JL. RAYA TLEKUNG NO.1 JUNREJO, BATU 0341-598911 Y Y ALL COVERAGE 598192/5 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1277 3620 APOTIK KIMIA FARMA 77 JL. 2K MALANG 0341-365298| - N Y 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 0341-325082 - 354844 - 354845/460341- 1281 0094 RSU. HERMINA TANGKUBANPRAHU MALANG JL. TANGKUBAN PRAHU, NO.33 MALANG 0341-354843 Y Y ALL COVERAGE 354844/8|0341-354844/8 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1284 2171 APOTEK FARMARIN MALANG JL. W. R.SUPRATMAN C2 KAV.9 MALANG 0341-334163/4| - N Y 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 JL. HOS. COKROAMINOTO NO.26 - 28, MAGERS. ARI,MOJOKERTO, JAWA 1288 1997 RS. ISLAM HASANAH MUHAMMADIYAH 0321-321635| - Y Y ALL COVERAGE TIMUR 61313 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 0321-322170/3221710321- 1291 0164 RS. REKSA WALUYA JL. MOJOPAHIT, NO.422 0321-322511 Y Y ALL COVERAGE 322171/3937|0321-322171/3937 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1294 3770 PRODIA PACITAN JL. NO. 14, PACITAN 63518 (0357) 884222| - N Y RB,PHAR PAMEKASAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1295 3811 APOTEK KIMIA FARMA 274 JL. DIPONEGORO No 4, PAMEKASAN 0324611332| N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1298 3626 KIMIA FARMA 165 JL. WAHIDIN SUDIRO HUSODO NO 59 PASURUAN 0343-426342| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1308 3847 APOTEK KIMIA FARMA 261 JL. MAJAPAHIT NO.35 SIDOARJO 0318956674| 318956674 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1309 3839 APOTEK KIMIA FARMA 119 PERUM DELTASARI BLOK AN NO 11 0318556411| 318556411 N Y RB,PHAR 1310 1108 RSAB. SOERYA JL. RAYA KALIJATEN, NO.11-15, TAMAN SEPANJANG 031-7885011-|- 031-7873633 Y Y ALL COVERAGE JL. DUSUN SEMAWUT, RT.10/RW.04, KEC. BALONGBENDO / JL. RAYA BY 1311 0927 RS. ANWAR MEDIKA 031-8972052, 8974943-|- 031-8988313 Y Y ALL COVERAGE PASS KRIAN KM.33 031-8962531-8961271031-8961271|031- 1312 0249 RS. DELTA SURYA JL. PAHLAWAN NO.9 031-8961281/8944977 Y Y ALL COVERAGE 8961271 1313 1346 RS. CITRA MEDIKA SIDOARJO JL. RAYA SURABAYA, KM.44, KRAMAT TUMENGGUNG 0321-361000| 0321-361666/362956 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1314 1339 KLINIK GRAHA MEDIKA JL. BRIGJEN KATAMSO NO.7 WARU 031 - 8554910| 031-8554911 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1315 3857 APOTEK KIMIA FARMA KAHURIPAN JL. KAHURIPAN NO.57 SIDOARJO 03151517736| 3151517736 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1316 3614 PRODIA SIDOARJO JL. PAHLAWAN 12A SIDOARJO (031) 8961010| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1317 3845 APOTEK KIMIA FARMA 180 JL. PAHLAWAN NO.10 SIDOARJO 0318947116| 318947116 N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1319 4706 KLINIK IBU & ANAK PONDOK JATI JL. PONDOK JATI AK 9-13 PAGERWOJO BUDURAN (031) 8052062| (031) 8052037 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1320 1342 KLINIK MEDIS GELORA PERUM TAMAN PINANG INDAH, BLOK B7, NO.3-3A 031-8929139| 031-8929123 N Y RB,PHAR 031- 1321 0545 RS.SITI KHODIJAH SIDOARJO JL. PAHLAWAN, NO.260, SEPANJANG 031-7876066 Y Y ALL COVERAGE 7881130,7882123,7872081,60134373| 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1324 2273 KLINIK & APOTEK KF 124 JL. RAYA SEDATI GEDE NO. 59 SIDOARJO 031 866 7929| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1325 1846 KLINIK MEDIS PUSURA SIDOARJO JL. RAYA CANDI NO. 49 SIDOARJO 031-8966345| 031-8075917 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1326 1336 KLINIK CITRA GADING MEDIKA JL. BRIGJEN KATAMSO BLOK A 408-409 REWIN WARU 031-8679727| 031-8683181 N Y RB,PHAR SITUBONDO

1327 3096 RS. ELIZABETH PTP NUSANTARA XI JL. WR SUPRATMAN 2A SITUBONDO 0338-671174| 0338-678061 Y Y ALL COVERAGE

SURABAYA 031- 5017975/5018335(021) 1328 0809 RS. SPESIALIS HUSADA UTAMA JL. PROF DR 31-35 031-5010777 Y Y ALL COVERAGE 9100682|(021) 9100682 1329 0081 SILOAM HOSPITALS SURABAYA JL. RAYA GUBENG NO. 70, SURABAYA 031-5031333/5031821| 031-5031533/5039313 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1330 5398 KLINIK KENCANA MEDIKA JL. RAYA KENDANGSARI NO. 78 SURABAYA (031) 8498880| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1331 3853 APOTEK KIMIA FARMA WIYUNG RUKO TPI BLOK A 17 RAYA MEGANTI SURABAYA 0317668267| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1334 3833 APOTEK KIMIA FARMA 24 JL. DHARMAWANGSA NO.24 0315032775| 315037664 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1337 3851 APOTEK KIMIA FARMA 432 PANDUGO JL. PANDUGO MERR NO.2 SURABAYA 0318709962| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1338 3852 APOTEK KIMIA FARMA G-WALK RUKO TAMAN GAPURO B.2, G-WALK SURABAYA 0317411121| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1339 3855 APOTEK KIMIA FARMA CILIWUNG JL. CILIWUNG NO.76 SURABAYA 0315633156| 315633156 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1340 3856 APOTEK KIMIA FARMA KLAMPIS JL. KLAMPIS JAYA BLOK A NO.30 SURABAYA 0315926293| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1341 3858 APOTEK KIMIA FARMA RUNGKUT JL. RUNGKUT MADYA NO.97 SURABAYA 0318721059| 318721059 N Y RB,PHAR 1342 2925 RS. MITRA KELUARGA KENJERAN JL. KENJERAN 506 (031) 99000880| (031) 99000885 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1343 3613 PRODIA DARMO PERMAI JL. RAYA DARMO PERMAI SELATAN 1F, SURABAYA 60226 (031) 7328866| N Y RB,PHAR 1344 4446 RSIA KENDANGSARI MERR JL. DR. IR. H. SOEKARNO NO. 2, SURABAYA (031) 3814388| (031) 3813488 Y Y ALL COVERAGE RS. PREMIER SURABAYA (RS. SURABAYA 1345 0829 JL. NGINDEN INTAN BARAT, BLOK B 031- 5993211|031-5993211 031- 5993214 Y Y ALL COVERAGE INTERNASIONAL) 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1351 4653 LAB KLINIK UTAMA BIOTEST SURABAYA JL KERTAJAYA INDAH F-304 SURABAYA 031-5929159/5929150| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1352 4128 LAB. PRODIA BOGOWONTO JL. BOGOWONTO NO.14 ( PUSAT GMC ) 031-5631818| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1353 3002 LAB. KLINIK BIOTEST SURABAYA JL. RA. KARTINI NO.78, SURABAYA, JAWA TIMUR (031) 5678736| - N Y RB,PHAR 1354 1365 RS. MATA UNDAAN JL. UNDAAN KULON, NO.19 031-5343806/531619| 031-5317503 Y Y ALL COVERAGE RUKO MEGA GALAXI, JL. KERTAJAYA INDAH TIMUR 14 C NO. 6, SURABAYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1355 3769 PRODIA MEGA GALAXI (UNDAAN) SBY (031) 5991010| - N Y 60282 RB,PHAR 1356 4082 RS. ISLAM DARUS SYIFA JL. RAYA BENOWO NO. 5 SURABAYA 0317406293| - Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1357 0548 KLINIK MEDIS PUSURA 3 (SUNGKONO) JL. MAYJEN, SUNGKONO, NO.64 031-5612120/22| 031-5668763 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1360 1548 KLINIK MEDIS PUSURA 5 (BALONGSARI) JL. BALONGSARI TAMA, BLOK B, NO.8-9 031-7416234| 031-7416234 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1361 0546 MEDIS PUSURA JL. KOM ( L) YOS SUDARSO, 9A 031-5340604 / 031-5471707/5328920| 031-5327095 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1364 0547 KLINIK MEDIS PUSURA 2 (RUNGKUT) JL. RUNGKUT ASRI TENGAH NO.2 031- 8705210| 031-8793028 N Y RB,PHAR 031- 1365 0544 RS. ST.VINCENTIUS A.PAULO (RS. RKZ) JL. DIPONEGORO NO.51 031-5674748/5651057 Y Y ALL COVERAGE 5677562/5687846/5663895031/5687846| 1366 0895 RS. PHC SURABAYA JL. PRAPAT KURUNG SELATAN NO.1 TANJUNG PERAK 031-3294801/2/3|- 031-3294804 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1367 0896 KLINIK KEBRAON JL. GRIYA KEBRAON BLOK FA NO.37 031-7663816-|- 031-7663816 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1368 0897 KLINIK BENOWO PONDOK BENOWO INDAH, BLOK PP/22 031-70547492-|- - N Y RB,PHAR 1369 2315 NATIONAL HOSPITAL SURABAYA BOULEVARD FAMILI SEL KAV 1 GRAHA FAMILI, SURABAYA 031-2975777| 031-297799 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1370 2639 LAB. PRODIA SURABAYA JL. DIPONEGORO NO.107 SURABAYA 60241 031-28953900| 031-5675476 N Y RB,PHAR 1371 2476 RS. ROYAL SURABAYA JL. RUNGKUT INDUSTRI I/ 1 SURABAYA 031-8476111| 031-8476211 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1372 2272 APOTEK KIMIA FARMA 35 JL. NGAGEL JAYA SELATAN NO. 107 SURABAYA 60258 031 504 1276, 504 9098| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1373 2212 APOTEK FARMARIN SURABAYA JL. JEMUR ANDAYANI II/1 031-8418190| - N Y 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 RSIA. PUTRI ( RS. KHUSUS OBSTETRI & 1379 1454 JL. ARIF RAHMAN HAKIM, NO.122 031-5999987| 031-5997215 Y Y ALL COVERAGE GINEKOLOGI ) 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1382 3831 APOTEK KIMIA FARMA 22 JL. BRATANG GEDE NO.100 A Surabaya 0315016713| 315016713 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1383 3832 APOTEK KIMIA FARMA 23 JL. KENDANGSARI BLOK J NO.7 0318414215| 318419345 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1384 3834 APOTEK KIMIA FARMA 25 JL. RAYA DARMO NO.2-4 0315677777| 315666454 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1385 3835 APOTEK KIMIA FARMA 26 JL. DIPONEGORO NO.94 0315677007| 315664420 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1386 3836 APOTEK KIMIA FARMA 45 JL. RAYA DARMO NO.94 0315676301| 315678819 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1387 3837 APOTEK KIMIA FARMA 52 JL. DUKUH KUPANG NO.54 0315671773| 315665755 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1388 3843 APOTEK KIMIA FARMA 166 JL. A.YANI 228 SURABAYA 0318291785| 318291785 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1389 3844 APOTEK KIMIA FARMA 175 JL. KARANG MENJANGAN NO.9 SURABAYA 0315991991| 315991991 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1390 3846 APOTEK KIMIA FARMA 243 JL. RAYA ARJUNO NO.151 SURABAYA 0315345031| 315459789 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1391 3165 LAB. PRODIA JEMURSARI JL. RAYA JEMURSARI NO.39, SURABAYA 031-8421010| 031-8438111 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1392 3848 APOTEK KIMIA FARMA 304 JL. PERAK TIMUR NO.166 SURABAYA 0313550007| 313550007 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1393 3850 APOTEK KIMIA FARMA 407 JL. MULYOSARI NO.288 SURABAYA 0315937994| 315937994 N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1400 3655 PRODIA TULUNGAGUNG JL. SUPRIADI NO.45 BLOK A.14, RUKO NIRWANA (0355) 336989| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1403 3708 APOTEK KIMIA FARMA 392 JL. NO. 10 TULUNGAGUNG 0355-322308| 0355-322308 N Y 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 JL. JUANG KM.1 NANGA PINOH, TANAH TINGGI RT.003/004 DESA TANJUNG 1405 5633 RS. KASIH BUNDA JAYA 0568-22885| Y Y ALL COVERAGE NIAGA JL.DHARMA BAKTI NO.45C DUSUN TANAH TINGGI DESA TANJUNG NIAGA 1406 5627 RS. CITRA HUSADA MELAWI 0568-22355| 0568-21645 Y Y ALL COVERAGE KEC.NANGA PINOH KAB.MELAWI PONTIANAK

1407 2729 RS. MITRA MEDIKA PONTIANAK JL. SULTAN ABDURRAHMAN NO.25, PONTIANAK, KALBAR (0561) 584888| - Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1408 2679 KIMIA FARMA SERDAM (SUNGAI RAYA DALAM) JL. SUNGAI RAYA DALAM RUKO B1 0561-737797| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1409 2253 KLINIK & APOTEK KF 32 PONTIANAK JL. TANJUNG PURA NO. 419 0561-731658| 0591-735802 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1410 2255 KIMIA FARMA 333 PONTIANAK JL. WAHID HASYIM NO.60 0561-768140| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1411 2254 APOTEK KIMIA FARMA 371 PONTIANAK JL. AHMAD YANI NO.5 0561-713988| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1414 3574 PRODIA PONTIANAK JL. AHMAD YANI NO.6C PONTIANAK 0561-736177| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1421 4393 KLINIK & APOTEK KF 111 JL. JEND. A.YANI NO.10 RT.10/001 0511-6749027 / 4772141| - N Y RB,PHAR BANJARMASIN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1422 3572 PRODIA BANJARMASIN JL. JEND. ACHMAD YANI KM 3.5 NO. 131 - 133 BANJARMASIN 70235 0511-3273500| N Y RB,PHAR 0511 - 3252570/3274447/3261491/0511- 1423 0631 RS. SARI MULIA JL. PANGERAN ANTASARI NO. 139B 0511 - 3257889 Y Y ALL COVERAGE 266960|0511-266960 0511-3350332, 3354896, 3350335|0511- 1424 0849 RS. ISLAM BANJARMASIN JL. LET JEN S PARMAN GG.PURNAMA NO.88 BANJARMASIN 0511-3351690 Y Y ALL COVERAGE 3350332/35 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1425 1758 KLINIK SPESIALIS SARI MULIA JL. PANGERAN ANTASARI NO. 139 B 0511-3254341/3266960/3252570| 0511-3266960 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1426 2236 APOTEK KIMIA FARMA 217 JL.A.YANI KM 2 NO.136 0511-3252250/3251369| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1427 2237 KLINK & APOTEK KF 188 JL. LETJEN S. PARMAN NO. 42 0511-3354020| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1428 2235 KLINIK & APOTEK KF 61 JL. VETERAN NO. 51 0511-3250682/3252779| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1429 2677 KLINIK & APOTEK KF 265 JL. A.YANI 49, KUALA KAPUAS 0513-21406| - N Y RB,PHAR BATU LICIN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1430 2471 KLINIK MEDIKA BATULICIN JL.RAYA BATULICIN - SERONGGO KM.1 SEI KECIL, TANAH BUMBU 0518-71570| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1432 4392 KLINIK & APOTEK KF 179 JL. JEND. A YANI KM.39.5 NO.47 0511-4722654| - N Y 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 JL. GAS, KOMPERTA MURUNG PUDAK TANJUNG, KALIMANTAN SELATAN 1435 2707 RS. PERTAMINA TANJUNG (0526) 2022550/2023068| (0526) 2027678 Y Y ALL COVERAGE 71571 TANAH BUMBU JL. GAWE SABUMI RT 08 NO. 083, DESA BERSU. JUD,KEC. SIMPANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1436 3996 KLINIK SIMPANG TANAH BUMBU (081258339911 / 081953230699)| - N Y EMPAT, KAB. TANAH BUMBU, KALIMANTAN SELATAN 72200 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1437 1011 KLINIK SURYA MEDIKA SATUI (SMS) JL. PROPINSI NO 11, RT 17 SUNGAI DANAU SATUI 0512-61717|0778-322122 0512-61312 N Y RB,PHAR KALIMANTAN TENGAH

MUARA TEWEH GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1438 2675 KLINIK & APOTEK KF 156 JL. Y.SINSENG NO.1 M.TEWEH, KALTENG 0519-21698| - N Y RB,PHAR PALANGKARAYA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1439 2673 KLINIK & APOTEK KF 112 (BM PALANGKARAYA) JL. DIPONEGORO NO.8, PAHANDUT 0536 -3221952| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1440 3764 PRODIA PALANGKARAYA JL. DIPONEGORO NO. 20 A-B, PALANGKARAYA (0536) 3235399| - N Y RB,PHAR RS. ISLAM PKU MUHAMMADIYAH 1441 2889 JL. RTA MILONO KM .2,5 MENTENG, JEKAN RAYA 0536-3244801-4803| 0536-3239444 Y Y ALL COVERAGE PALANGKARAYA PANGKALAN BUN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1442 3529 KLINIK KESUMA JL. ISKANDAR NO.12 A, PANGKALAN BUN 0532-2065244 / (0532) 23935| (0532) 23935 N Y RB,PHAR JL. MALIJO, MADUREJO, ARUT SELATN, KOTAWARINGIN BARAT, 1443 4676 RS. CITRA HUSADA PANGKALAN BUN (0532) 2070777| (0523) 2070789 Y Y ALL COVERAGE KALIMANTAN TENGAH SAMPIT GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1444 4085 KLINIK SARI MEDIKA SAMPIT JL. P.ANATASARI NO 5 SAMPIT 0531-25288; 0531-24396| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1445 2672 KLINIK & APOTEK KF 103 JL. H.M ARS. YAD, NO.120, SAMPIT 0531-24828| - N Y RB,PHAR KALIMANTAN TIMUR

BALIKPAPAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1446 1520 APOTEK KIMIA FARMA 56 JL. A.YANI, NO.95 0542-412244, 424187,7031852| 0542-731560 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1447 3459 SUMATERA EYE CENTRE BALIKPAPAN RUKO SENTRA EROPA BLOK AA 2B NO.16 BALIKPAPAN BARU (0542) 876732/876941| - N Y RB,PHAR 0542-877898,72040460751- GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1448 0686 PANACEA CLINIC KOMP MAL FANTASI BLOK AB2 NO.18-20 BALIKPAPAN BARU 76114 0542-877641/7031819 N Y 444712/5|0751-444712/5 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1449 0692 APOTIK KANIDA FARMA II JL. JEND. SUDIRMAN, NO. 239 0542-424309,0542 420496|0542-420496 0542-424031 N Y RB,PHAR

Page 21 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1450 1457 KLINIK & APOTEK KF 136 BALIKPAPAN JL. MT. HARYONO NO. 72 0542-763962| 0542-761629 N Y RB,PHAR 1451 0672 RSIA. PERMATA HATI BALIKPAPAN JL. IMAM BONJOL NO.1 0542-413932/413928| 0542 - 413928 Y Y ALL COVERAGE JL. MULAWARMAN NO. 24 RT 7 MANGGAR BARU BALIKPAPAN, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1452 2073 KLINIK MEDIKA UTAMA ( KMU SETIARA ) 0542-770846| 0542-770847 N Y KALIMANTAN TIMUR RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1453 2632 KLINIK & APOTEK KF 293 JL. A. YANI NO.45 KARANG JATI 0542 792420| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1454 2633 KLINIK & APOTEK KF 68 JL. JEND.SUDIRMAN NO.2-3 PERTOKOAN KLANDASAN 0542 422691| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1455 2635 KLINIK & APOTEK KF 329 JL. SOEKARNO HATTA KM 5 / 86, BPN 0542 860024| - N Y RB,PHAR 1456 1213 RS. BALIKPAPAN BARU KOMP. BALIKPAPAN BARU JL. MT.HARYONO BLOK. A-A3 0542-877330| 0542-877331 Y Y ALL COVERAGE SILOAM HOSPITALS BALIKPAPAN (RS 1457 1374 JL. MT.HARYONO NO.9 RINGROAD 0542 - 8862 999| 0542-7206517 Y Y ALL COVERAGE BALIKPAPAN HUSADA) GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1458 2634 KLINIK & APOTEK KF 425 SEPINGGAN JL. MARS. MA NO. 702 0542 7210391| - N Y 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 KOMP. PERTOKOAN BANDAR KLANDASAN BLOK D-11, JL. JEND. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1461 3573 PRODIA BALIKPAPAN 0542-739337| - N Y SUDIRMAN, BALIKPAPAN 76113 RB,PHAR 0542-427342/3/40542-427342|0542- 1462 0632 RS. RESTU IBU BALIKPAPAN JL. JEND. A. YANI, NO.12 0542-441494/417290 Y Y ALL COVERAGE 427342 BATU KAJANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1463 1767 KUSUMA MEDICAL CENTER BATUKAJANG JL. NEGARA KM.141 RT 09C PASER 0543-5230262| - N Y 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. 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1467 3874 KLINIK SATELIT 3 RS. PKT BONTANG JL. LETJEN S PARMAN NO. 5 BONTANG 0548-23388| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1468 2474 KLINIK RS. PKT 1 JL. IMAM BONJOL BONTANG-KALTIM 0548-24800| - N Y RB,PHAR KUTAI KARTANEGARA JL. RA. KARTINI RT. 21, DESA GAS ALAM MUARA BADAK, KUTAI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1469 3707 KLINIK QICA 082227276911| - N Y KARTANEGARA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1470 1074 KLINIK MAJU SEJAHTERA JL. MOH. HATTA, HANDIL 3, MUARA JAWA 0541-691891/ 081333001836-|- 0541-691892 N Y RB,PHAR PASER JL. NEGARA KM. 140 NO. 09 RT. 009 KEC BATU SOPANG KAB PASER GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1471 5520 KLINIK ATHIRAH 081257436633 / 081255578967| - N Y KALTIM RB,PHAR SAMARINDA

1472 1794 RSIA. THAHA BAKRIE JL. PANGERAN HIDAYATULLAH NO 11 SAMARINDA 0541-742191| 0541-200075 Y Y ALL COVERAGE JL. CIPTO MANGUN KUSUMO RT 12 NO 52 KEL SENGKOTEK LOA JUAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1473 1656 KLINIK MELATI HUSADA 0541-260721| 0541-241752 N Y SAMARINDA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1474 2104 KLINIK & APOTEK KF 105 JL. DR. SUTOMO NO 36-37 SAMARINDA 0541-741639| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1475 2105 KLINIK & APOTEK KF 138 KARTIKA JL. KH NO. 30 SAMARINDA 75121 0541-737447| N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1478 3813 KLINIK & APOTEK KF 385 (PPO) JL. P.M.I NO.25 SAMARINDA 0541-734334| - N Y RB,PHAR JL. A. YANI (PEMUDA II) NO.3, RT. 10 - KEL. TEMINDUNG PERMAI KEC. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1479 4795 KLINIK SILOAM SAMARINDA (0541) 2090 900| - N Y SUNGAI PINANG, SAMARINDA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1480 3575 PRODIA SAMARINDA JL. A. YANI KOMP. CENDRAWASIH TRADE CENTER BLOK A-6, SAMARINDA (0541) 736198| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1481 3460 SUMATERA EYE CENTRE SAMARINDA JL. A. YANI NO. 6 A-B SAMARINDA (0541) 200257, 200258| - N Y RB,PHAR 0541-742161/748309/7483100541- 1482 0636 RS. DIRGAHAYU JL. GN. MERB. ABU, NO. 62 0541-748308/744636 Y Y ALL COVERAGE 748309/10/11|0541-748309/10/11 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1483 2631 KLINIK & APOTEK KF 114 SAMARINDA JL. P.HIDAYATULLAH NO.63, SAMARINDA 0541 742198| 0541 742198 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1484 5666 KLINIK KUMALA JL. P. ANTASARI NO. 33 B RT. 02 SAMARINDA 75124 (0541) 735602/ 769357| - N Y RB,PHAR 1485 2473 RS. SIAGA RAMANIA JL. RAMANIA 3 ( JL. JEND. SOEPARTO) SAMARINDA, KALTIM 0541-739772| 0541-749131 Y Y ALL COVERAGE

SANGATTA RS. PKT PRIMA SANGATTA (RS. PUPUK KALTIM 1486 1376 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1489 4681 KLINIK BUNYU MEDIKA JL. EMPLASMEN RT. 07 DESA BUNYU TIMUR, KAB. BULUNGAN (0511) 2055374| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1503 5124 LAB. PRODIA TELUK BETUNG Jl. Ikan Hiu Teluk Betung 085768958661| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1504 2110 KLINIK & APOTEK KF 131 BANDAR LAMPUNG JL. KARTINI NO. 44-45 BANDAR LAMPUNG 0721240291| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1505 2112 KLINIK & APOTEK KF 327 BANDAR LAMPUNG JL. JEND. SUDIRMAN NO. 88 BANDAR LAMPUNG 0721- 5600608| - N Y RB,PHAR JL. K.H. HASYIM ASHARI NO. 73, TELUK BETUNG SELATAN - BANDAR 1506 2176 RSIA. RESTU BUNDA 0721-484158/484185| 0721-482832 Y Y ALL COVERAGE LAMPUNG 1507 2465 RSIA. PURI BETIK HATI JL. PAJAJARAN NO.109, JAGABAYA, BANDAR LAMPUNG, LAMPUNG 0721-787799| - Y Y ALL COVERAGE JL. NEGARA LINTAS SUMATERA KM.65 YUKUM JAYA - BANDAR JAYA, KEC. 1508 2767 RS. ISLAM ASY-SYIFAA (0725) 25264| (0752) 527476 Y Y ALL COVERAGE TERB. ANGGI BESAR, LAMPUNG TENGAH 34162

Page 22 of 28 NOV-08-2017 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1509 2725 THC TELKOM MEDIKA LAMPUNG EX. GEDUNG PLASA TELKOM JL. SULTAN AGUNG NO. 1 BANDAR LAMPUNG 0721703044/ 704999| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1511 4394 KLINIK & APOTEK KF 222 JL. GAJAH MADA NO.58B BANDAR LAMPUNG 0721 5601300| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1512 2901 LAB. PRODIA PAHOMAN LAMPUNG JL. JEND. SUDIRMAN NO. 120 PAHOMAN LAMPUNG 0721-8017700/1| - N Y RB,PHAR LAMPUNG SELATAN JL. IR. SUTAMI KM.30 DESA MALANG SARI, TANJUNG SARI-LAMPUNNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1513 3170 KLINIK DUA PUTRI JAYA 085366797190| - N Y SELATAN RB,PHAR JL. IR. SUTAMI NO. 153, DESA LEMATANG, KEC. TANJUNG BINTANG, KAB. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1514 4523 KLINIK LEMATANG MEDICAL CENTER (0721) 350145; 0823 0607 2345| - N Y LAMPUNG SELATAN 35361 RB,PHAR METRO GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1515 4516 PRODIA METRO JL. JEND SUDIRMAN NO. 37 LAMPUNG 0725-7855205| - N Y 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 JL. N. SOEKARNO - HATTA NO : 94, TANJUNG HARAPAN, KOTABUMI, 1517 2921 RSU. HANDAYANI 0724328399| Y Y ALL COVERAGE LAMPUNG UTARA MALUKU

AMBON JL. DR. KAYADOE, KEL. KUDAMATI, AMBON-MALUKU(DI DALAM RS. GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1518 2265 APOTEK KIMIA FARMA PEL.26 AMBON,MALUKU 0911-351677| - N Y HALAUSSY) 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1522 2264 LAB. PRODIA AMBON JL. ANTHONY RHEBOK NO: 1 B-C 0911-314296| - N Y RB,PHAR MALUKU UTARA

TERNATE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1523 2259 LAB. KLINIK PRODIA TERNATE JL. A. MONONUTU NO:21 TERNATE, MALUKU UTARA 0921-3111246| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1524 2260 KLINIK & APOTEK KF 168 TAKOMA TERNATE JL. HASAN ESA 151 TERNATE, MALUKU UTARA 0921-3121037/3123076| - N Y 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 JL. SEKOLAH MO. 5 GAMPONG ATEUK PAHLAAWN KEC. BAITURRAHMAN 1527 4836 RS. PERTAMEDIKA UMMI ROSNATI (0651) 35092| - Y Y ALL COVERAGE KOTA BANDA ACEH GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 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 Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1530 2187 APOTEK KIMIA FARMA 402 LAMPRIET JL. TEUKU DAUD BEUREUEH NO. 167-171 0651-637008| 0651-635 669 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1533 1789 KLINIK SPECIALIS CEMPAKA LIMA JL. TENGKU M. DAUD BEUREUEH NO 156 0651-33345 / 08126922264| - N Y 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

JL. BANDA ACEH-MEDAN KM. 220 NO. 102 DUSUN TERATAI GAMPONG 1535 6082 RSU. JEUMPA HOSPITAL (0644) 324150| - Y Y ALL COVERAGE GEULANGGANG BARO, KEC. KOTA JUANG, KAB. BIREUEN, ACEH

1536 1694 RS. TELAGA BUNDA BIERUN JL. PEUTUA BANTA NO.7, GP BIREUN 0644-324433| 0644-324433 Y Y ALL COVERAGE

LANGSA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1537 2667 KLINIK & APOTEK KF 81 JL. TM.ZEIN NO.1E ,LANGSA,ACEHTIMUR 0641-21020| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1540 2903 LAB. PRODIA LHOKSEUMAWE JL. MERDEKA NO. 18 LHOKSEUMAWE ( DEPAN TELKOM ) 0645-47205| - N Y RB,PHAR JL. DARUSSALAM NO. 36 KP JAWA BARU, KOTA LHOKSEUMAWE - ACEH GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1541 1975 KLINIK VINCA ROSEA 0645-7011117 / 46725/ 085338437373| 0645-630218 N Y UTARA RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1542 2119 KLINIK & APOTEK KF 60 JL. MERDEKA NO. 47 B -C LHOKSEUMAWE BANDA ACEH 0645-41152| - N Y RB,PHAR MEULABOH 082361103699/08116822077/081269802 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1543 4212 KLINIK CEMPAKA LIMA MEULABOH JL. SWADAYA NO 39 F/39 G MEULABOH N Y 42| RB,PHAR 1544 3686 RS. SWASTA MONTELLA JL. BERINGIN JAYA SAMPING MESJID AGUNG, MEULABOH, ACEH BARAT (0655) 7551974; 085277358711| - Y Y ALL COVERAGE

PIDIE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1545 4106 KLINIK MUTIARA SIGLI JL. PROF A. MADJID IBRAHIM NO. 10, SIGLI, PIDIE, ACEH 24151 0653-21529| 0653-24565 N Y RB,PHAR SIGLI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1546 3958 KLINIK & APOTEK KF 397 SIGLI JL. PERDAGANGAN NO.1 SIGLI - ACEH 065321536 / 085265313030| 65321536 N Y RB,PHAR NTB

BIMA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1547 3506 KIMIA FARMA NO. 263 BIMA JL. SOEKARNO - HATTA NO. 3 BIMA 0374-42910| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1548 3453 LAB. PRODIA BIMA JL. SOEKARNO HATTA NO. 39 D BIMA 0374-646910| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1550 3503 KIMIA FARMA NO. 55 SELONG JL. M. YAMIN NO. 77 SELONG - LOMBOK TIMUR -| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1552 3452 LAB. PRODIA MATARAM JL. PEJANGGIK NO. 107 MATARAM 0370-635248; 635010| - N Y RB,PHAR KIMIA FARMA NO. 231 MATARAM (Group KF GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1553 3504 JL. SALEH SUNGKAR NO. 33 AMPENAN -| - N Y 189) RB,PHAR KIMIA FARMA 458 CATUR WARGA (Group KF GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1554 3507 JL. CATUR WARGA NO. 17 MATARAM -| - N Y 189) RB,PHAR KIMIA FARMA NO. 234 MATARAM (Group KF GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1555 3505 JL. SELAPARANG NO. 53 MATARAM -| - N Y 189) 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1559 2258 KLINIK & APOTEK KF NO. 189 JL. SRIWIJAYA NO. 295 MATARAM 0370-633211| - N Y RB,PHAR JL. AHMAD YANI NO. 9 SELAGALAS, SANDUBAYA, MATARAM - LOMBOK 1560 1645 RS. HARAPAN KELUARGA MATARAM 0370-670000,6177027,6177000| 0370-673666 Y Y ALL COVERAGE (NTB) GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1561 4688 KLINIK PRATAMA ASY-SYIFA JL. PANJI TILAR NEGARA NO. 136 MATARAM -| - N Y RB,PHAR 1562 1124 RSB. EXONERO JL. PEMUDA NO.16, DASAN AGUNG 0370-636454,644440| 0370-647023/636454 Y Y ALL COVERAGE 0370-632117/0370) 632117 / 0878 651 1563 1539 RS. RISA SENTRA MEDIKA JL. PEJANGGIK, NO.115, CAKRANEGARA 0370-625559 Y Y ALL COVERAGE 29354 / 089 7090 1005/06/56/0370- 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

SUMBAWA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1565 3482 KIMIA FARMA NO. 303 SUMBAWA JL. CENDRAWASIH SUMBAWA BESAR 0371 - 24029| - N Y RB,PHAR NTT

ENDE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1566 3500 APOTEK KF KELIMUTU ENDE JALAN KELIMUTU ENDE (0381)-2627456| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1571 3494 LAB. PRODIA KUPANG JL. CAKDOKO NO. 52 KUPANG (0380)-824566, 821010, 8080020| - N Y RB,PHAR 1572 3975 SILOAM HOSPITALS KUPANG JL. RW MONGINSIDI RT. 014 RW. 004 FATUTULI 0380-8530900/8530911| 0380-8530933 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1573 2666 KLINIK & APOTEK KF LALAMENTIK JL. WJ.LALAMENTIK,95 D-E, KUPANG 0380-840362| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1574 1380 KLINIK & APOTIK KARTINI JL. ELTARI I NO.2 0380-833010| 0380-820660 N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1576 2242 KLINIK & APOTEK KF 135 KUPANG Jl. M.Hatta 46 Kupang 0380- 830944/820541/831296| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1577 2245 KLINIK & APOTEK KF 101 KUPANG JL. HEREWILA NO. 38 KUPANG 0380- 827270| - N Y RB,PHAR LABUHAN BAJO JL. GABRIEL GAMPUR RT.013. RW.005, DUSUN V, KEC. KOMODO, KAB. 1578 4762 SILOAM HOSPITALS LABUAN BAJO (0385) 238 1900 EXT. 22001| (0385) 238 1911 EXT. Y Y ALL COVERAGE MANGGARAI BARAT, LABUHAN BAJO SIKKA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1579 3616 LAB. KLINIK PRODIA MAUMERE JL. EL TARI, KEL. MADAWAT, KEC. ALOK, MAUMERE FLORES (0382) 21146| - N Y RB,PHAR PAPUA

JAYAPURA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1580 4203 LAB. KLINIK CITO JL. ARGAPURA NO. 11 E, JAYAPURA 0967-522080 / 085244202002| 0967-522082 N Y RB,PHAR 0967-573479/ 572325; 0852 4400 1581 1469 RS. DIAN HARAPAN JL. TARUNA BHAKTI KEL YABANSAI DISTRIK HERANG - JAYAPURA 0967-573362/573979 Y Y ALL COVERAGE 4655;0813 44100 432| GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1582 2188 KLINIK & APOTEK KF 172 JAYAPURA JL. AHMAD YANI NO. 67,JAYAPURA 0967-534921/533 322| 0967-534921 N Y RB,PHAR MERAUKE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1583 4213 LAB. KLINIK CITO MERAUKE JL. RAYA MANDALA 293, MERAUKE PAPUA 0971-325367| 0971-325368 N Y RB,PHAR TIMIKA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1584 2732 KLINIK PURI HUSADA JL. BUDI UTOMO UJUNG, TIMIKA PAPUA (0901) 3126661/081240760444| - N Y 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 RS. ANGKATAN LAUT DR AZHAR ZAHIR 1586 4181 JL. SERMA SUWANDI NO. 1 0986-211758; 0822-38980-504| - Y Y ALL COVERAGE MANOKWARI 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1589 2766 KLINIK IGA DUMAI JL. SUTAN SYARIF KASIM NO.221, DUMAI - RIAU 0765-4397481/ 085264881796| N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1591 4169 KLINIK CITRA MEDIKA JL. M. YAMIN SH NO. 58, DUMAI (0765) 38508; 4300044| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1593 0922 KLINIK THURSINA JL. JEND SUDIRMAN NO.65 SIMPANG PADANG 0765-595573|0765-595573 0765-595573 N Y RB,PHAR 0765-94902/95799, GIGI913670765-0765- 1594 0921 RS. PERMATA HATI DURI JL. JEND SUDIRMAN NO.37 SIMPANG PADANG 0765-595799 Y Y ALL COVERAGE 596899|0765-0765-596899 1595 0930 RSU. THURSINA JL. HANGTUAH NO.93 0765-597782 / 595573|0765-595573 0765-597773 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1596 4121 LAB. PRODIA DURI JL. HANG TUAH 105 D, DURI 0765-93008| - N Y 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 JL. BIMA NO. 1 NANGKA UJUNG, KEL. DELIMA KEC. TAMPAN, PEKANBARU, 1598 4853 RS. PRIMA PEKANBARU (0761) 8419007| (0761) 8419006 Y Y ALL COVERAGE RIAU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1599 4689 PRODIA PEKANBARU(PHC) JL. JENDRAL SUDIRMAN NO. 203 L-M PEKANBARU (0761) 8403383, 856739| - N Y 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. 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 JL. SOEKARNO HATTA NO.236 KEL.SIDOMULYO TIMUR, KEC MARPOYAN 1606 5205 RS. MATA PEKANBARU EYE CENTER 07617875191-92| 0761-7875195 Y Y ALL COVERAGE DAMAI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1607 3568 PRODIA PEKANBARU JL. CEMPAKA NO. 80 B-C, PEKANBARU, RIAU 28156 0761-45542| N Y RB,PHAR 1608 0920 RS. AWAL BROS PEKANBARU JL. JEND. SUDIRMAN NO.117 0761-47333-|- 0761-47222 Y Y ALL COVERAGE KLINIK MATA SUMATERA EYE CENTER GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1609 2837 JL. ARIFIN AHMAD NO. 58 PEKANBARU 0761-565686| 0761-565786 N Y PEKANBARU RB,PHAR 1610 0663 RSIA. ERIA BUNDA JL. KH. AHMAD DAHLAN, NO.163 0761-23100/23600| 0761-47235 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1611 2101 APOTEK KIMIA FARMA 229 JL. SUDIRMAN 724 0761 29186| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1612 2102 APOTEK KIMIA FARMA 93 JL. JEND. SUDIRMAN NO 175 0761-32796| - N Y 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 JL. GARUDA NO. 66 TASKURUN UNJUNG TANGKERANG TENGAH, 1615 2590 RSB. ANNISA TANGKERANG (0761) 848 652| (0761) 848 652 Y Y ALL COVERAGE PEKANBARU JL. HR. SOEBRANTAS RT. 01/RW. 03 NO 88 KEL. TUAH KARYA KEC. 1616 2468 RS. AWAL BROS PANAM 0761-586 888| 0761 586111 Y Y ALL COVERAGE TAMPAN PANAM, PEKANBARU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1617 3003 PRAKTEK DRG. TENSY A. T JL. AHMAD YANI 111C ( APOTEK PANGEAN ) PEKANBARU 081365910510 ; 081364223894| - N Y RB,PHAR 1618 1535 EKA HOSPITAL PEKANBARU JL. SOEKARNO HATTA, KM.6,5 0761-6989999| 0761-6989944 Y Y ALL COVERAGE

ROKAN HILIR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1619 2199 KLINIK AGUNG JL. JEND. SUDIRMAN KM. 8, BAGAN BATU 0765-552459| 0765-552459 N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

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 JL. ENGKU PUTRI, KOMPLEKS MAHKOTA RAYA BLOK E NO. 12A-12B, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1623 3608 PRODIA BATAM (0778) 7495735| N Y BATAM CENTRE - BATAM 29432 RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1624 4336 KLINIK DUNIA MEDICAL CENTRE RUKO PERUMNAS FANINDO BLOK B NO. 7-10, BATAM 29432, KEP. RIAU (0778) 7432 899| (0778) 3581209 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1625 4150 KLINIK & APOTEK KF NO. 230 PANBIL MALL BLOK A NO. 5 0778-371149| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1626 6018 KLINIK MUTIARA AISYAFA KOMPLEK RUKO TAMAN CARINA BLOK 3 NO.5 BATU AJI 0778-7432804 / 081374682228| 0778-7432804 N Y RB,PHAR 1627 1010 RS. ST. ELISABETH - BATAM JL. ANGGREK BLOK II, BALOI 0778 - 457357-|- 0778-457710/422473 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1628 0485 GENTA MEDICAL CENTER MUKA KUNING INDAH, BLOK F, NO.10 0778-361909| - N Y 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 KOMPLEK RUKO SAGULUNG PERMAI BLOK B14-15, SAGULUNG KOTA, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1631 2448 YAHYA MEDICAL CENTER & APOTIK ZAHRUNI (0778) 392748| (0778) 392749 N Y BATAM RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1632 2479 KLINIK & APOTEK KF 413 KOMP. RUKO BOTANIA GARDEN BLOK A 1 NO. 1 C - BATAM 0778 7431199| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1633 2480 KLINIK & APOTEK KF 128 KOMP. PERTOKOAN WIJAYA BLOK A NO. 4 SEI HARAPAN - BATAM 0778 323697| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1634 2482 KLINIK & APOTEK KF 269 JL. JEND SUDIRMAN, BATAM CENTRE, BATAM 0778 461482; 363375| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1635 2486 KLINIK & APOTEK KF 137 KOMP.SAGULUNG MAS INDAH B3, BATAM 0778 392146| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1636 2487 KLINIK & APOTEK KF 224 KOMP MUKA KUNING INDAH II B2.3, BATAM 0778 363375| - N Y 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 GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1640 1241 KLINIK BERSALIN ERNES JL. PERMAISURI NO.8 TANJUNG UBAN 0771-483212| 0771-482738 Y Y 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

JL. CANGGAI PUTRI TELUK UMA KABUPATEN KARIMUN PROVINSI 1642 1271 RS. BAKTI TIMAH KARIMUN 0777-7367085| 0777-7333251 Y Y ALL COVERAGE KEPULAUAN RIAU 29661 JL. RAJA OESMAN RUKO TAMAN ANGGREK NO.5 BATU LIPAI RT.002 /001, GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1643 5782 KLINIK NAYA MEDIKA 0777-327842| - N Y KEL.BARAN TIMUR, KEC. MERAL RB,PHAR H&S,GP,SP,OP,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1644 0874 RSB. GRAHA RAP JL. R.USMAN, BATU LIPAI, TANJUNG BALAI 0777-326097| 0777-323857 Y Y RB,PHAR JL. AHMAD YANI, KOMPLEK KARIMUN INDAH, BLOK B, NO.1, TANJUNG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1645 1208 MEDIC CENTRE CLINIC 0777- 325 561| 0777- 325561 N Y BALAI RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1646 1237 KLINIK SAYANG IBU JL. AHMAD YANI, NO.20, BARAN SATU, MERAL, TANJUNG BALAI 0777- 216 76| 0777- 222 52 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1647 1291 APOTIK DEVI FARMA JL. AHMAD YANI, SEI PASIR, MERAL, TANJUNG BALAI 0777-21388| 0777-368974/21388 N Y RB,PHAR TANJUNG PINANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1648 2483 KLINIK & APOTEK KF 31 JL. BINTAN 656-658,TG.PINANG 0771 22879, 21091| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1649 4397 KLINIK & APOTEK KF 297 JL. BANTAR CETEK KM.9 TANJUNG PINANG 0771 441619| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1650 4416 KLINIK & APOTEK KF 169 JL. BRIGJEND. KATAMSO, TG.PINANG(JL. KM 4 NO. 3) 0771 - 317631| N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1651 3766 PRODIA TANJUNG PINANG JL. IR. SUTAMI, RUKO VILLA AKASIA NO. 20 (0771) 25305| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1652 4396 KLINIK & APOTEK KF 109 JL. MT.HARYONO KM.3,5 TANJUNG PINANG 0771 313590| - N Y RB,PHAR SULAWESI BARAT

MAMUJU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1653 4521 PRODIA MAMUJU JL. ABD WAHAB AZASI NO. 43 MAMUJU 081513905286| - N Y 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 GP,SP,OP,DENTAL,MAT,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1656 2717 KLINIK & APOTEK KF 38 JL. HASANUDDIN, NO.46, MAKASSAR 0411- 3617110| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1657 2904 KLINIK PRODIA MAKASSAR (SADDANG) JALAN SUNGAI SADDANG NO.40 MAKASSAR (0411) 872727/446666| (0411) 873110 N Y RB,PHAR JL. BOULEVARD RUKO RUBY I NO. 7-8, PANAKKUKANG MAS, MAKASSAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1658 2905 KLINIK PRODIA MAKASSAR (JOKO WIDODO) (0411) 446666| (0411) 457000 N Y 90222 (PUSAT GMC - PPS PANAKKUKANG) RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1659 4161 KLINIK & APOTEK KF GOWA JL. SULTAN HASANUDDIN NO. 8 GOWA 0411-869842|- - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1660 4163 KLINIK & APOTEK KF MAROS JL. POROS MAROS MACCOPA 0411-372020|- - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1661 1388 RATULANGI MEDICAL CENTRE JL. NO.28 0411-878605/06/88| 0411-878587 N Y 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 KLINIK & APOTEK IMEDICAL SPECIALIST GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1666 4415 JL. RACING CENTRE NO. 17 MAKASSAR (0411) 4668835| (0411) 4668834 N Y CENTRE RB,PHAR KLINIK TELKOMEDIKA MAKASSAR (THC GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1667 4817 Jl. DR. RATULANGI NO. 126 MAKASSAR 0411 8122283 / 081355551600| - N Y MAKASSAR) RB,PHAR 1668 1630 RS. AWAL BROS MAKASSAR JL. JEND. URIP SUMOHARJO NO.43 MAKASSAR 0411-454567/455558| 0411-455123 Y Y ALL COVERAGE 0411- 1669 1190 RS. AKADEMIS JAURY YUSUF PUTERA JL. JEND. M YUSUF NO. 47A, PATTUNUANG 0411-313914 Y Y ALL COVERAGE 3617343/3613054/3613071/3617344| GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1670 2291 KLINIK & APOTEK KF 199 ERLINA JL. URIP SUMOHARJO NO. 32 MAKASSAR 0411 449 936| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1671 2657 KLINIK & APOTEK KF HERTASNING JL. HERTASNING NO 11 - MAKASSAR 0411- 442945| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1672 2658 KLINIK & APOTEK KF 33 JL. AHMAD YANI, NO.17 - 19, MAKASSAR 0411-3616722| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1673 2659 KLINIK & APOTEK KF PETTARANI JL. PETTARANI 18, MAKASSAR 0411-857210 / 857215| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1674 2660 KLINIK & APOTEK KF DAENG TATA JL. DAENG TATA 69, MAKASSAR 0411-880685| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1675 2661 KLINIK & APOTEK KF 250 JL. DR.RATULANGI 59, MAKASSAR 0411- 582895| - N Y RB,PHAR 0411- 1676 1847 SILOAM HOSPITALS MAKASSAR JL. METRO TANJUNG BUNGA KAV.9 PANAMBUNGAN, MARISSO 0411-8117911 Y Y ALL COVERAGE 3662900/8117555/8117430/5290000| 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1680 5237 CEREBELLUM CLINIC JL. SWADAYA NO. 4, MAKASSAR (0411) 427184| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1681 2178 APOTEK FARMARIN MAKASSAR JL. LANDAK LAMA NO 27, KEL LABUANG BAJI KEC MAMAJANG 0411-870397| - N Y RB,PHAR JL. TODDOPULI RAYA TIMYUR LORONG MAKASSAR BORONG KEC. 1682 5593 RS. HERMINA MAKASSAR (0411) 4091817| (0411) 4091775 Y Y ALL COVERAGE MANGGALA 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

1685 4985 RSU. WISATA UNIVERSITAS INDONESIA TIMUR JL. ABDUL KADIR NO. 70, MAKASSAR, 90224 (0411) 888444, 888666| (0411) 8115656 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1686 5145 PRODIA-BATU PUTIH JL. G. BATU PUTIH NO. 25, MAKASSAR -| - N Y RB,PHAR PALOPO GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1687 3772 LAB. PRODIA PALOPO JL. NO. 53, PALOPO 91921 (0471) 327467| - N Y RB,PHAR 1688 0914 RS. AT MEDIKA JL. ANDI JEMMA, NO.09 0471-21596-|- 0471-23008 Y Y ALL COVERAGE

PARE PARE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1689 3773 LAB. PRODIA PARE PARE JL. ANDI MAPPATOLA NO. 7, PARE-PARE 91114 (0421) 22265 / 7007433| - N Y RB,PHAR 1690 1394 RS. FATIMA PARE-PARE JL. ILHAMV KOTAK POS 12 0421-21847| 0421-21328 Y Y ALL COVERAGE

SENGKANG GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1691 4129 LAB. PRODIA SENGKANG JL. AP PETTARANI NO.18, SENGKANG 0485-323409| - N Y RB,PHAR SULAWESI TENGAH

PALU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1692 3577 KLINIK PRODIA PALU JL. S. PARMAN NO. 16, PALU 94111 0451-451639| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1693 2288 KLINIK & APOTEK KF 390 PALU JL. SETIABUDI NO. 65 D PALU SULTENG 0451-425132| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1694 2287 APOTEK KIMIA FARMA 449 TATURA JL. WOLTER MONGINSIDI NO. 145 PALU, SULTENG 0451-429832| - N Y 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 JL. SULTAN HASANUDDIN No. 58, KEL.BATULO, KEC.WOLIO KOTA BAUBAU, 1696 4761 SILOAM HOSPITALS BUTON 0402-2825555| (0402) 2823020 Y Y ALL COVERAGE SULAWESI TENGGARA JL. SULTAN MURHUM NO. 69 KEL. WAJO KEC. MURHUM SULTENG, BAU 1697 2300 RS. MURHUM 0402-2822650| 0402-2823919 Y Y ALL COVERAGE BAU KENDARI

1698 1537 RS. ST. ANNA JL. DR. MOH.HATTA, NO.65A 0401-3123092| 0401-3124872 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1699 2286 KLINIK & APOTEK KF 288 JL. A. YANI NO. 84 KENDARI 0401 319 6186| - N Y RB,PHAR KLINIK & APOTEK KIMIA FARMA 104 (BM GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1700 2285 JL. HOMAMMAD HATTA NO.77, KENDARI BARAT 0401 -3127182| - N Y KENDARI) RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1701 3576 PRODIA KENDARI JL. SAOSAO NO. 207 KENDARI 0401-3121789| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1702 6229 KLINIK DIAGNOSTIK RAPHA KENDARI JL. MALAKA NO. 25 ANDUONOHU, KENDARI 0401-3081484| - N Y RB,PHAR SULAWESI UTARA

KOTAMOBAGU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1703 3762 PRODIA KOTAMOBAGU JL. D.I. PANJAITAN NO. 13, KOTAMOBAGU 95176 (0434) 2629104| - N Y RB,PHAR MANADO GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1704 4245 KLINIK & APOTEK KF TUMINTING MANADO JL. HASANUDIN NO 137 MANADO 0431 855420| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1705 4244 KLINIK & APOTEK KF 290 MANADO JL. MARTHADINATA RAYA NO. 38 0431 861878| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1708 2875 POLIKLINIK PERTAMINA MANADO JL. SAM RATULANGI N0.8 MANADO -| - N Y RB,PHAR KOMPLEKS BAHU MALL BLOCK. C NO. 23) JL. N. WOLTER MONGINSIDI NO. 1709 2805 RSIA. KASIH IBU MANADO 0431 834780/834667| 0431 834721 Y Y ALL COVERAGE 1 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1710 2296 THC MANADO JALAN WR SUPRATMAN NO. 5 MANADO 0431- 843363| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1711 2230 KLINIK & APOTEK KF NO. 74 JL. SAM RATULANGI NO.31 MANADO 93117 0431-864012| 0431-850838 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1712 2232 KLINIK & APOTEK KF WENANG 309 JL. LIMIMUNT NO. 12 A KEL. TIKALA KUMARAKA, KEC. WENANG, MANADO 0431-867163/840087| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1713 2233 LAB. PRODIA MANADO JL. SAM RATULANGI NO. 72 MANADO 95111 0431-874567| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1714 2231 APOTEK KIMIA FARMA MALALAYANG KP. REL NO. 5 RS. VP MALALAYANG 0431-838278| 0431-838277 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1715 2656 KLINIK & APOTEK KF 129 JL. A.YANI, SARIO, MANADO 0431- 861571| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1716 2650 KLINIK & APOTEK KF 331, BAHU JL. W.MONGINSIDI 29 A,MANADO 0431-842786| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1717 2654 KLINIK & APOTEK KF 332 JL. SAM RATULANGI NO.338,, WANEA 0431- 843002| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1719 2114 KLINIK & APOTEK KF 146 BUKIT TINGGI JL. JEND. SUDIRMAN NO 14 BUKIT TINGGI 0752-35700| - N Y RB,PHAR 1720 1398 RSU. MADINA JL. GURU HAMZAH NO.17 0752-21388 EXT 228| 0752-626677 Y Y ALL COVERAGE GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1721 3602 PRODIA BUKIT TINGGI JL. A. RIVAI 23, BUKIT TINGGI 26116 (0752) 23348| N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1725 2060 KLINIK & APOTEK KF 94 PADANG JL. PROKLAMASI N. 24 PADANG 0751-891195| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1726 2113 KLINIK & APOTEK KF 238 PADANG JL. PATIMURA NO 18 PADANG 0751-23620| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1734 4805 ZIRCONIC DENTAL CLINIC JL. H. AGUS SALIM NO. 57 B PADANG (0751) 841917; (0811666310)| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1735 3569 PRODIA PADANG (JL. ) JL. PATTIMURA NO. 3 A, PADANG 25113 0751-38795| N Y RB,PHAR 1736 4051 RSIA. SITI HAWA JL. PARAK GADANG RAYA NO.35 0751-841251| - Y Y ALL COVERAGE JL. RATULANGI NO. 24 RT. 001 RW. 008, KEL. KAMPUNG JAO, KEC. 1737 4794 RS. NAILI DBS (0751) 8951900 ; 8951901| (0751) 8951902 Y Y ALL COVERAGE PADANG BARAT 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1740 2115 KLINIK & APOTEK KF 372 PAYAKUMBUH JL. JEND. SUDIRMAN PAYAKUMBUH -| KF_ N Y 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 LIST PROVIDER PT. ASURANSI AXA INDONESIA - ADMEDIKA 8-Nov-17

No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed

LUBUK LINGGAU GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1742 1869 KLINIK SEKATA JL. YOS SUDARS. O NO. 230 TABAH JEMEKEH, LUBUK LINGGAU 0733-321357| - N Y 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 KLINIK BERSALIN KARUNIA INDAH MEDIKA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1744 5778 JL. MAYOR TJI AGUS KIEMAS LINTAS KEPUR - MUARA ENIM 081273373378| N Y (KIM) 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 JL. DEMANG LEBAR DAUN RT 035 RW 010, KELURAHAN DEMANG LEBAR 1750 4034 RSIA. SITI MIRZA 0711-446272| 0711-441345 Y Y ALL COVERAGE DAUN, KECAMATAN ILIR BARAT I 0711-312866,3118660711-311866|0711- 1751 0883 RS. BUNDA PALEMBANG JL. DEMANG LEBAR DAUN, PALEMBANG 0711-355553 Y Y ALL COVERAGE 311866 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 0711-364954,362766, 374802, 1754 0885 RSIA. YK. MADIRA JL. JEND SUDIRMAN NO.1051 C-D PALEMBANG (0711) 356173 Y Y ALL COVERAGE 3747850711-356173|0711-356173 1755 0803 RS. MYRIA JL. KOL. H. BURLIAN KM. 7 NO 228 PALEMBANG 0711-411610/412433/421914| 0711-414052 Y Y ALL COVERAGE 0711-350426/3533750711- 1756 0817 RS. RK. CHARITAS JL. JEND. SUDIRMAN NO.1054 0711-362205/377088 Y Y ALL COVERAGE 353374/5|0711-353374/5 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1757 2394 KIMIA FARMA 239 JL. MP. MANGKUNEGARA 0711 - 823503| - N Y 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1759 2442 KLINIK PRODIA PALEMBANG JL. BASUKI RAHMAT NO.801 PALEMBANG 30113 0711-411304| 0711-5610294 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1760 2185 KLINIK & APOTEK KF 209 JL. LETKOL ISKANDAR NO. 222 0711354717/0711362245| - N Y RB,PHAR JL. PENGANTINGAN NO.1 KOMPLEK PERTAMINA PLAJU SUMATERA 1761 2787 RS. PERTAMINA PLAJU PERTAMEDIKA (0711) 597401/597442| (0711) 542388 Y Y ALL COVERAGE SELATAN 30268 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1762 4132 LAB. PRODIA VETERAN JL. VETERAN 930/C2, 9 ILIR, PALEMBANG 0711-377239/362487| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1763 2839 POLIKLINIK PERTAMINA PALEMBANG JL. JEND. AHMAD YANI NO. 1247. 1 PALEMBANG -| - N Y RB,PHAR PENUKAL ABAB LEMATANG ILIR JL. TAMAN SISWA KELURAHAN PASAR BHAYANGKARA ,KEC TALANG UBI, 1764 2152 RSUD. TALANG UBI 0713-390487/0713-390566-391111| 0713-391456/390487 Y Y ALL COVERAGE KAB PENUKAL ABAB LEMATANG ILIR PRABUMULIH

1765 3953 RS. FADHILAH JL. JENDRAL SUDIRMAN NO. 01 PATIH GALUNG PRABUMULIH (0713) 3300032; 323939;| (0713) 3300032 Y Y ALL COVERAGE 0713- 1766 0824 RS. PERTAMINA PRABUMULIH JL. KESEHATAN, NO.100, KOMPLEK PERTAMINA PRABUMULIH 0713-321903/325181 Y Y ALL COVERAGE 383333/382749/322069/382742/382731( 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. 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 GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1772 3722 PRODIA BINJAI JL. SUDIRMAN NO. 25, BINJAI 20714 (061) 8828269| - N Y 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 JL. BAKARAN BATU DESA TEMPATAN KEC. BERINGIN, NO. 45 KAB. DELI 1776 2348 RS. PATAR ASIH LUBUK PAKAM 061-7950449,50| 061-7950313 Y Y ALL COVERAGE SERDANG JL.BESAR NAMORAMBE NO. 10 -15, KEC. NAMORAMBE DESA DELI TUA 1777 4359 RS. THEOTOKOS (061) 7032854; 7032694;| (061) 7032806 Y Y ALL COVERAGE MEDAN 20355 KARO GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1778 4118 LAB. PRODIA KABANJAHE JL. VETERAN NO. 21 ( RSU ESTER ) KABANJAHE, KARO 0628-323321| - N Y RB,PHAR KISARAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1779 3730 PRODIA KISARAN JL. IMAM BONJOL NO. 177, KISARAN 21222 (0623) 348599| - N Y 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

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1781 4119 LAB. PRODIA LUBUK PAKAM JL. AHMAD DAHLAN NO. 69, LUBUK PAKAM 061-7952030| - N Y 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

061-7861771,7864656061-7864656|061- 1788 1061 RS. ESTOMIHI JL. SISINGAMANGARAJA NO.235 MEDAN 061-7866660 Y Y ALL COVERAGE 7864656

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 061- 1796 1651 RS. BUNDA THAMRIN MEDAN JL. SEI BATANG HARI NO. 28/30 MEDAN SUNGGAL 4553928,88813615,4557318,4557218,455 061-4558218 Y Y ALL COVERAGE 3918| 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

061-7362777 / 7360120 / 7367980 EXT. 1798 0322 RSU. PERMATA BUNDA MEDAN JL. SISINGAMANGARAJA, NO.7 061-7320222 Y N ALL COVERAGE 141|

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No Code Hospital Name Address Tel Number Fax Number RI RJ Allowed RS. COLUMBIA ASIA MEDAN (D/H GLENI 1799 0590 JL. LISTRIK 2A MEDAN 061-4566368| 061-4566585/4515453 Y Y ALL COVERAGE MEDAN)

1800 4092 RSIA. SRI RATU JL. NIBUNG RAYA NO 204-212 MEDAN 061-4521074| 061-4539236 Y Y ALL COVERAGE

JL. A.R. HAKIM NO. 168, KEL. SUKA RAMAI I, KEC. MEDAN AREA, KOTA 1801 4001 RS. MADANI MEDAN 061-7345911, 061 - 7361357| Y Y ALL COVERAGE MEDAN GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1802 2900 LAB. PRODIA JL. ASIA MEDAN JL. ASIA NO. 115B MEDAN 061-7321260| - N Y 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

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1805 2876 KLINIK PRODIA MEDAN S PARMAN JL. LETJEND S PARMAN NO. 17/223 G LT LI 20153 MEDAN 061-4535731 / 4534903| - N Y 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

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1808 3767 PRODIA MEDAN SETIA BUDI KOMPLEKS RUKO MILALA MAS BLOK A NO. 8, SETIA BUDI, MEDAN (061) 8224129| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1809 3768 PRODIA MEDAN (GATSU) JL. JEND. GATOT SUBROTO NO.129, MEDAN 20112 (061) 4157459| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1810 2182 KLINIK & APOTEK KF 27 JL. PALANG MERAH NO. 32 061-4576023/4515513| 061-451551 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1811 2179 APOTEK FARMARIN MEDAN JL. GATOT SUBROTO KM 4,2 NO. 311 MEDAN PETISAN 061- 4528454| 061- 4528464 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1812 2183 KLINIK & APOTEK KF 39 JL. GATOT SOEBROTO NO 37 A/C 061-4529909| 061-4532717 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1813 2438 E-LABS MEDAN JL. SENA NO.10 MEDAN 061-4101293| 061-4530850 N Y 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

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1818 0418 KLINIK SPESIALIS BUNDA JL. SISINGAMANGARAJA NO.17 061 -7321666| 061-7344786 N Y 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

JL. KH. DEWANTARA SIHUBUAN KEC. BARUMUN KAB. PADANG LAWAS, 1820 4861 RSU. PERMATA MADINA SIBUHUAN (0636) 421211| (0636) 421311 Y Y ALL COVERAGE SUMUT

PADANG SIDEMPUAN

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1821 3771 PRODIA PADANG SIDEMPUAN JL. MERDEKA NO 52 PADANG SIDEMPUAN 22718 (0634) 7366622| - N Y RB,PHAR

PEMATANG SIANTAR

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1822 2208 KIMIA FARMA 29 SOETOMO JL. SUTOMO NO.63 PEMATANG SIANTAR 0622-22447| 0622-25527 N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1823 2209 APOTEK & KLINIK KIMIA FARMA KARTINI JL. KARTINI NO. 19 PEMATANG SIANTAR 0622-22448| 0622-25527 N Y 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

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1826 4418 KLINIK & APOTEK KF 162 JL. KARTINI PEMATANG SIANTAR 0622-22448| - N Y RB,PHAR GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1827 2898 LAB. PRODIA PEMATANG SIANTAR JL. MERDEKA NO 37 PEMATANG SIANTAR 0622-22437| - N Y RB,PHAR

RANTAU PRAPAT

GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1828 3785 LAB. PRODIA RANTAU PRAPAT JL. AHMAD YANI NO. 197, RANTAU PRAPAT 21415 (0624) 25368| - N Y RB,PHAR SIBOLGA GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1829 3566 LAB. PRODIA WIDYAHUSADA SIBOLGA JL. S.M. RAJA NO.74B 0631-22539| - N Y RB,PHAR 1830 2249 RS. METTA MEDIKA SIBOLGA JL. NO.34 / JL. DIPENOGORO 6-8 SIBOLGA 0631-25007/25008/24001/24002| 0631-25006 Y Y ALL COVERAGE

TANJUNG BALAI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1831 4120 LAB. PRODIA TANJUNG BALAI JL. SUDIRMAN NO. 23, TANJUNG BALAI - KARIMUN 0623-596227| - N Y RB,PHAR TEBING TINGGI GP,SP,OP,DENTAL,LAB,RM-RI,RM-RJ,RM-RG,RM-KM,RM- 1832 3787 LAB. PRODIA TEBING TINGGI JL. SUDIRMAN NO. 257 D, TEBING TINGGI 26014 (0621) 22494| - N Y 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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