7/24/2019 UBAH FASKES (1)

1/16

FORM MUTASI DATA PESERTA

JENIS PESERTA

NAMA INSTANSI/BADAN/PERUSAHAAN

KODE VIRTUAL ACCOUNT

BANK TEMPAT PEMBAYARAN IURAN

TANGGAl REGISTRASI

NOMOR PKS

KODE PKS

MASA BERLAKU

KODE TANGGUNGAN

KODE KC

KODE DATI2

No

1 2 3 41 0001431789366 3 10/10/2015

2 0001431789401 3 10/10/2015

3 0001431789467 3 10/10/2015

4 0001609646038 3 10/10/2015

5 0001609646049 3 10/10/2015

6 0001609646051 3 10/10/2015

7 0001140416234 3 10/10/2015

8 0001192160845 3 10/10/2015

9 0001192160856 3 10/10/2015

10 0001126531978 3 10/10/2015

11 0001180809077 3 10/10/2015

12 0001180809088 3 10/10/2015

13 0001180809099 3 10/10/2015

14 0001875689796 3 10/10/2015

15 0001125614766 3 10/10/2015

16 0001177122835 3 10/10/2015

17 0001181055611 3 10/10/2015

18 0001837896625 3 10/10/2015

19 0001183627574 3 10/10/2015

20 0001609644723 3 10/10/2015

21 0001609644734 3 10/10/2015

22 0001224209564 3 10/10/2015

23 0001224209619 3 10/10/2015

24 0001126537334 3 10/10/2015

25 0001177122508 3 10/10/2015

26 0001177122519 3 10/10/2015

27 0001177122521 3 10/10/2015

28 0001224757091 3 10/10/2015

29 0001609644262 3 10/10/2015

30 0001609644273 3 10/10/2015

No Ka!" BPJS

K#$#%a!a& '#$#!a

J#&($

M"!a$(

T)l A*!(+B#la*"M"!a$(

7/24/2019 UBAH FASKES (1)

2/16

31 0001609644284 3 10/10/2015

7/24/2019 UBAH FASKES (1)

3/16

No KK NIK/KITAS/KITAP

, -

7/24/2019 UBAH FASKES (1)

4/16

7/24/2019 UBAH FASKES (1)

5/16

A3

PT. ALFA KARSA PERSADA

1141341

Na0a L#&)*a'

Ko# H"K#l T)l

T#0'a! La%(

5SUGIARTO 1

YULIANA 3

PUTRI NUR HALIFAH 4

YANA MULYANA 1

ELIS BADRIAH 3

DIMAS EKA WIJAYA 4

SUWANDI HARYONO 1

RINI 3

YOLANDA JULITA 4

AGUS WIYONO 1

DEWI BUDI ASTUTI 3

AGDELIA MELVA AZARINE 4

AGDELIA KANESHYA FIRHANI 4

SITI ZULAEHA SOLEHAH 3

PASKAH ROMPAS 1

ROSLELI 3

VALERIA NAOMI ROMPAS 4

IMANUEL JEREMIA ROMPAS 4

ZALFAA ZAKIYYAH PUTRI 4

JOKO SANTOSO 1

MURNI AWALIYAH 3

SYAFIRA FEBRIYANI SANTOSO 4

ILHAM PUTRA SANTOSO 4

IWAN MARWAN 1

ENTINI KARTINI 3

ASEP KURNIAWAN 4

SAEFUL KURNIAWAN 4

SALFI HAERUNISA 4

ARI PRABOWO 1

YUNI YELMAWATI 3

1 6 P#$#!a

2 6 S"a0(3 6 I$!(4 6 A&a*

, 6 Ta0a%a&

7/24/2019 UBAH FASKES (1)

6/16

KAYLA RIFDA YURI 4

7/24/2019 UBAH FASKES (1)

7/16

a%(

Na0a Fa$*#$ T*.I

/00/7777

1 2224/3/1985 Klinik Indosehat 2003 Clincing

15/7/1993 Klinik Indosehat 2003 Clincing

03/11/2012 Klinik Indosehat 2003 Clincing

06/05/1983 Rawa Tembaga

20/12/1987 Rawa Tembaga

31/07/2010 Rawa Tembaga

15/07/1981 Klinik Indosehat 2003 Clincing

21/05/1985 Klinik Indosehat 2003 Clincing

22/07/2005 Klinik Indosehat 2003 Clincing

10/11/1969 Klinik MULIA MEDIKA (JST)

10/04/1974 Klinik MULIA MEDIKA (JST)

24/05/2004 Klinik MULIA MEDIKA (JST)

10/02/2009 Klinik MULIA MEDIKA (JST)

27/07/1989 PADANG CERMIN

30/04/1972 KEL. SUNTER AGUNG III

29/11/1977 KEL. SUNTER AGUNG III

12/05/2011 KEL. SUNTER AGUNG III

01/11/2013 KEL. SUNTER AGUNG III

14/03/2009 SURADADI

22/06/1981 Klinik Syifa Medical Center

25/02/1992 Klinik Syifa Medical Center

06/02/2008 Klinik Syifa Medical Center

16/08/2011 Klinik Syifa Medical Center

13/06/1961 Klinik Indosehat 2003 Clincing

10/06/1975 Klinik Indosehat 2003 Clincing

01/07/1994 Klinik Indosehat 2003 Clincing

08/03/1997 Klinik Indosehat 2003 Clincing

26/12/2003 Klinik Indosehat 2003 Clincing

16/06/1990 Klinik Indosehat 2003 Clincing

25/06/1991 Klinik Indosehat 2003 Clincing

7/24/2019 UBAH FASKES (1)

8/16

02/08/2014 Klinik Indosehat 2003 Clincing

7/24/2019 UBAH FASKES (1)

9/16

E0a(l

23 24 2, 2-

Ko#Fa$*#$

Do*!#G()(

Na0a Fa$*#$

Do*!# G()(

No0o T#l#'o&

P#$#!a

7/24/2019 UBAH FASKES (1)

10/16

7/24/2019 UBAH FASKES (1)

11/16

NIP Jaa!a&

S!a!"$ K#la$ Ra8a!

2 2 25 3

16T#!a'9

26Ko&!a*936Pa"% 8a*!"46P#(0aP#&$("&

16K#la$ I926K#la$ II936K#la$ III

7/24/2019 UBAH FASKES (1)

12/16

7/24/2019 UBAH FASKES (1)

13/16

A$"a&$( La(&&7a

1=WNI, 2=WNA a!" A$"

31 32 33 34 3, 3-

TMT K#:a ;Ka7.

A*!(+